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ft9v 

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P.H.  Cruner 


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1 

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aux sont  filmes  en  commengant  par  la  premiere 
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qui  comporte  une  telle  empreinte. 

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signifie  "FIN". 

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filmes  a  des  taux  de  reduction  differents.  Lorsque 
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un  seul  cliche,  il  est  filme  a  partir  de  Tangle 
sup6rieur  gauche,  de  gauche  a  droite,  et  de  haut 
en  bas,  en  prenant  le  nombre  d 'images 
necessaire.   Les  diagrammes  suivants  illustrent  la 
methode. 


1 

2 

3 

4 

5 

6 

MICROCOPY    RESOIUTION   TEST   CHART 

'ANSI  and  ISO  TEST  CHART  No    2! 


1.0   !^»-  m 


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*^—     ■•6'  ..e:   0300  -  Ohone 

^=  ;  '161  288  -  5989  -  Fo« 


^.^■. 


STUDIES    IN    PUNCTURE-FLUIDS 


STUDIES    IN 
PUNCTURE-FLUIDS 

A    CONTRIBUTION    TO    CLINICAL 
PATHOLOCJY 


MKI\(;    A    THKSIS  Al'PROVKO  FOR  THK   DKGRKK  OK   D()(   lOR 
OF    MKDIC  INK    IN    THK    ITNIVF.RSITV    OF    LONDON 


O.  C.  GRUNEK,  M.D.  London 

clinical  Pathologist  at  the  General  liifinnarv,  l.eeJi ;  late 
Hon.  Pathologist  to  the  Leeds  Puhlii  Dispensary 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO. 

I0I2    WALNUT  STREET 
1908 


I'rinted  in  Engiaiid] 


^i     .Civ^  190? 


TO 


MY    MOTHER 


55059 


PREFACE 

It  has  now  l^ecome  generally  recognised  how  great  is  the  as- 
sistance which  the  detailed  chemical  and  physical  examination 
of  morbid  material  affords  the  physician  or  surgeon  in  arriving 
at  or  confirming  a  diagnosis.  In  carrying  out  the  research 
recorded  in  this  book,  the  requirements  of  the  clinical  pathologist 
have  therefore  been  steadily  kept  in  view. 

Probably  the  greatest  value  of  future  investigations  into 
the  nature  and  comjwsition  of  puncture-fluids  will  be  found 
to  lie  in  the  additional  light  they  may  be  expected  to  throw 
ufwn  the  subject  of  metabolic  processes  in  diseases.  At  present 
the  available  data  are  so  scanty  that  it  is  impossible  to  treat 
this  subject  in  detail,  but  it  is  hoped  that  the  special  index 
referring  to  the  puncture-fluids  met  with  in  different  morbid 
conditions  may  prove  useful. 

My  grateful  thanks  are  due  to  the  members  of  the  Honorary 
Staff  of  this  Infirmary,  who  have  kindly  permitted  me  to  publish 
the  results  of  my  work  upon  their  cases  ;  to  Dr.  G.  W.  Watson 
and  Mr.  J.  A.  Coupland  for  assistance  in  tracing  the  clinical 
records  of  the  cases  studied  ;  and  to  the  various  members  of 
the  Infirmary  Staff  who  have  preserved  material  for  analysis. 
Lajtly  I  must  gratefully  acknowledge  the  debt  I  owe  to  the 
writers  of  the  works  I  have  consulted  during  the  course  of  my 
researches. 

O.  C.  GRUNER. 

i'athological  laboratory, 

Genrral    Infirmary,    Leeds, 

July  1908. 


vil 


CONTENTS 


INTRODUCTION 

Objects  of  study— The  caution  necessary  in  interpreting  results,  owing 
to  the  existence  of  important  variables — The  insight  into  metabolic  pro- 
cesses afforded  by  the  chemistry  of  puncture-fluids— The  decomposition 
products  of  proteid  may  be  either  initially  present,  or  artificially  produced 
by  analytical  processes— The  main  methods  of  physico-chemical  analysis 
The  scheme  of  examination  of  fluids — Cytodiagnosis  .         .         .     />.   i 


SECTION   I 

THE  CHEMICAL   EXAMINATION   OF 
PUNCTURE-FLUIDS 

Preliminary  remarks— Difficulties  attached  to  the  analysis  of  fluids- 
Precipitation  of  albumen  by  mastic,  etc.— Adsorption— Scheme  for  analysis 
of  puncture-fluids.  (A)  Preliminary  processes.  (B)  Separation  of  the 
globulins— Albumen— Globulin— Albumoses  and  peptones— Monamino- 
acids— Ammonia— Hydrolysis— Sugars— Purins  and  urea.  (C)  Diamino- 
acids— Residual  nitrogen.  (D)  The  glycoproteids ;  pseudo-mucin,  its 
properties  and  reactions  ;  paramucin  ;  synovin — Lecithin,  its  importance, 
constitution,  allies,  and  symbiotic  •substances,  and  methods  of  analysis— 
The  diazo-reaction — The  a-naphthol  reaction — Ehrlich's  glucosamine 
reaction — Tryptophane — Pigment — The  inorganic  constituents  of  punc- 
ture-fluids— Ferments,  their  detection,  their  occurrence,  and  their  im- 
portance   p.  10 


SECTION   II 

THE   PHYSICO-CHEMICAL  EXAMINATION   OF 
PUNCTURE-FLUIDS 

(A)  Osmotic  pressure — Theoretical  considerations  on  osmotic  pressure  ; 
how  to  calculate  the  osmotic  pressure  ;  the  degree  of  dissociation — Theo- 
retical considerations  on  electroconductivity  ;  corrections  necessary'  for 
vanations  in  temperature  and  in  amount  of  prote.ii  in  the  solutions 
examined  ;     achloride    electrolytes — Osmotic    concentration — Theoretical 

ix 


X  CONTENTS 

considerations  dealing  with  the  effect  of  mixtures  of  many  substances 
on  the  freezing-point  depression  and  on  electroconductivity — The  relation 
of  freezing-point  depression  to  specific  gravity — Methods  of  determining 
the  freezing-point  depression  and  the  electroconductivity — Results  of 
examination  in  each  case — The  plasmolytic  metho<l ;  Hamburger's  adapta- 
tion to  the  study  of  body-fluids  ;  Wright's  method — Other  methods  of 
determination  of  osmotic  pressure.  (B)  The  critical  solution  point. 
(C)  The  concentration  of  the  hydrogen  ions  ;  theoretical  considerations  ; 
meaning  of  the  term  acidity — The  indicator  method  of  estimating  the 
reaction  oi  a  fluid — The  inversion  methot! — The  methyl-acetate  method 
— The  dilatonieter  method — The  diazoacetic-ether  method — The  concen- 
tration-chain method  ;  the  gas  chain  ;  a  few  details  as  to  the  method  of 
carrying  out  this  method  ;  the  results  which  have  been  obtained  by  Foi. 
and  by  Pfaundler — Significance  of  the  results.  (D)  Viscosity — The 
viscosimeter  of  Hess  ;  method  of  use  ;  the  theory  of  the  instrument  ; 
results  of  examination  of  puncture-fluids.     (E)  Refractometry     .     p.  gi 


SECTION    III 

THE  CHARACTERS   POSSESSED   BY  VARIOUS 
PUNCTURE-FLUIDS 

The  lymph— Pus— Pleural  fluids — Peritoneal  fluids— Opalescent  or 
turbid  effusions — Effect  of  repeated  tapping — Chyle — Pericardial  fluid — 
Synovial  fluid— Hydrocele  fluid — Aqueous  humour— Amniotic  fluid — 
Cerebrospinal  fluid— Cysts  :  ovarian,  pancreatic,  thyroid,  liver,  kidney 
spleen,  lymphatic,  lacteal,  parotid,  bone,  spermatocele,  hydatid    .     p.  142 


SECTION    IV 

THE   DIFFERENTIAL   DIAGNOSIS  OF 
EXUDATES   FROM  TRANSUDATES 

Deductions  to  be  made  from  :  (a)  specific  gravity,  (6)  amount  of 
total  proteid,  (c)  refractometry,  (rf)  viscosity,  (f)  presence  of  serosa- 
mucin,  (/)  Rivalta's  test,  (?)  presence  of  fructose,  etc.,  {h)  presence  of 
ferments,  («)  effect  of  oral  administration  of  drugs,  (;)  reaction  with 
immune  serum,  {k)  evidence  furnibhed  by  the  chloride  versus  achloride 
electrolytes.    (/)  cytodiagnosis p,   196 


SECTION    V 
CYTODIAGNOSIS 

Sources  of  failure  in  practical  diagnosis — Methods  of  examination — 
The  results  afforded  by  cytodiagnosis— ! ieinz'  researches— Lymphocytes, 
pseudo-lymphocytes,  polynucleosis,  endothelial   cells,  large  mononuclear 


CONTENTS 


xi 


cells,  eosinophile  cells,  mast  cells,  red  blood  cells,  carcinoma  cells— The 
special  features  of  hydrocele  fluid,  of  joint  fluids,  of  cerebrospinal  fluid- 
Ovarian  cysts— Special  findings  in  the  deposit  of  puncture-fluids— Artificial 
scheme  for  cytodiagnosis— The  chemistry  of  the  cell-elements     .     />.  3i8 


SECTION   VI 
SPECIAL  CASES 

p.  236 


APPENDIX 

Table      I.  Ready  Reckoner  for  Chlorides  .         .         .         . 

Table     II.  Ready    Reckoner    for    Molecular    Concentration    of 

Sodium  Chloride  Solutions 
Table  III.  Specific  Conductivity  of  Potassium  Chloride 
Table  IV.  Rate  of  Migration  of  Ions 

Table    V.  Obach's  Table  

Table  VI.  Ready  Reckoner  for  Osmotic  Concentration 


Index  of  Diseases 
Literature 
Index  of  Authors 
General  Index 


P-    253 

*54 
256 

257 
257 
260 


XVM 
263 

281 


LIST  OF  FIGURES 


VAOB 

1.  Adsorption 

2.  Device  for  Burettes 3 

3.  Velocity  of  Reaction ' 

4.  Scheme   of   Apparatus  for    determining   Electroconduc- 

TIVITY 

5.  Hamburger's  Pipette "^ 

6.  The  Critical  Solution  Point ^^^ 

7.  Diagram  to  illustrate  the  Meaning  of  the  term  "  Acidity  "     123 

8.  Diagram    showing    the    Apparatus   for    determining    the 

Concentration  of  Hydrogen  Ions  in  a  Puncturk-Fluid  .     129 

9.  The  Viscosimeter  of  Hess ^30 

to.  From  a  Cysto-Adenoma  Papilliform  Ovarii.       .        .  174 

11.  From  a  Multilocular  Ovarian  Cyst 178 

12.  From  a  Cysto-carcinoma  Ovarii *78 

13.  From  a  Multilocular  Ovarian  Cyst I79 

14.  Dead  and  Dying  Cells  from  a  Colloid  Carcinoma    .        .179 


xiii 


LIST  OF  TABLES   RECORDING  THE 
AUTHOR'S  RESULTS 


PAOB 
26 


TABLE 

I.  Globulin-content  of  Puncture-Fluids  . 
II.  Albumoses  in  Puncture-Fluids       .... 

III.  Urea-content  of  Puncture-Fluids         ....  3° 

IV.  I'uRiNs  in  Puncture-Fluids 3' 

V.  Mucins  in  Puncture-Fluids 4^ 

VI.  Lecithin  in  Body-Fluids 54 

VII.  The  a-NAPHTHOL  Reaction  of  Puncture-Fluids    .        .  57 

VIII.  Tryptophane  in  Puncture-Fluids 59 

IX.  Chlorides 61 

X.  Ferments  in  Puncture-Fluids 80 

XI.  Autolysis  in  Puncture-Fluids 85 

XII.  The  Dissociation  of  a  Pleural  Fluid  ....  98 

XIII.  Relation  of  Specific  Gravity  to  Freezing-point  De- 

pression    109 

XIV.  Viscosity  of  Puncture-Fluids 141 

XV.  Constituents  met  with  in  some  of  the  Fluids  examined  153 

XVI.  Osmotic   Concentration   of   Pleural   and   Peritoneal 

Fluids 154 

XVII.  Electrolytes  in  Cerebrospinal  Fluid  ....  173 

XVIII.  Osmotic  Concentration  of  Ovarian  Cyst-Fluids  .         .  182 

XIX.  Electrolytes  in  Ovarian  Cyst-Fluids  .         .         .         .183 

XX.  Pancreatic  Cyst-Fluids 185 

XXI.  Specific  Gravity 198 

XXII.  Percentage  of  Albumen  in  Various  Fluids          .         .  202 
XXIII.  Chloride  vetsus  Achloride  Electrolytes  in  Exudates 

AND  Transudates 212,  213 


r*oa 
«7 


xvi     LIST  OF  TABLES  RECORDING   AUTHOR'S  RESULTS 

Unnumbered : 

Adsorption  Experiments 

Degree  of  Dissociation  of  Bile iw 

Electrolytes  in  (Edema  Fluid '45 

Composition  of  Peritoneal  Fluid  on  Successive  Tappings  157 

Osmotic  Concentration  of  Cerebrospinal  Fluid        .         .  171 

Records  of  Special  Cases      .        .     238,  241.  M*.  243.  244.  246 


INDEX  TO  DISEASES  REFERRED  TO   IN 
THIS  WORK 


\cuto  Hhfiniiatisni,  l2.^ 
Akoliolisiii,   H)'»  1 7^. 
Amyloid   Disease,   2,< 
\namia.   82 

Hantis  Uisoasc,  34,   MM 
Cardiac  railiire.  Z},.  25.  2<),  J".  3'- 
34.  4>.  54.  57.  3'J.  f"-  **"•  '4'' 
■50.    "SJ.    '54-    '55.    i'3'    •«37' 

247,    2.S'> 

Adherent     I't-ricardiiiin,     i'',     59, 

141.  -4'> 
Cirrhosis  ot   Liver,   25.    2<',   3".   3'- 
41,    51,    5'»,   '>!,    80.    14'.    '44. 
i4'».    15".    153.    •54.    15''.    157. 

■!I3.    243 
Monolol)iilar,  54,  2ui,  245,  248-y 

Syphilitic,   i')i 
Eclampsia,  170 
Empyema,   2'>,   30,   31,  59,  f)i,  80, 

84.  141,  147,  212.  228,  240 
Gout,  ifi3 
Jaundice,   170 
Lung,  Gangrene  of,  80 
Malignant  Disease — 

Stomach,  30,  41.  61,   153,  247 

Liver,  I47 

Pancreas,  41 

Omentum,  30,  31,  61,   153,  212, 

242,  246 
Peritoneum,    3.    11,    23,    26,    30, 
31.    41.    54.    55.    59,    61,    141, 
150,    154,    157.    200,    206,    212, 
229.   239 
Meningitis,  16;,  108,  i;o 

Tuberculous,  lOO,   168,   171,   172, 

17K,  230,  232 
Pachy-,  Hsemo.,   168 
Multiple  Lymphoma,  150 
MultipleMyeloma,   150 


Nervous  Diseases— 
Apoplexy,  167,   169 
Cerebellar  Abscess,  172 
Cerebral  Hx-morrhage,   167 
Cerebrospinal  Fever,   167,   231 
Disseminated  Sclerosis,  if>g 
Epilepsy,  169,   172 
Herpes,  230 

Hydrocephalus,  170,   171 
Mental  :    Acute  Amentia,   i')8 

Amaurotic  Idiocy,   if>8 
Dementia     Paralytica, 
T67,  169,171.  172,  230 
Hysteria,  i<^'8,   ifK) 
Neurasthenia,   169 
Tabes,  168,  169,  172,  229.  230,  231 
Tumor  Cerebri,  167,  168,  169,  173 
(Edema  sine  Albuminuria,  80 
Pericarditis  (tuberculous),   162 
Peritonitis  — 
Acute,  155 
Chronic,   30,    31,  41,   26,   54,   55. 

59,  61,  80,  154,  212,  248 
Puerperal,   147 
Suppurative,   154 
i        Tuberculous,   23,  25,   30,  41,   54. 
j  57.   59,  61.   80,    141,   150,   153, 

I  154.   155'  200,  212 

Pleurisy  — 

Postpneumonic,  212,  239 
Simple,    25.    26,   30,   31,   41,   57, 
I  59,  61,  80,  141,  150,   154,  237, 

!  238,  242 

i       Tuberculous,   25,   26,  30,  31,  4', 
55-  57.  59.  (^i,  80,  83,  147,  153. 
154,  201,  212,  237,  239 
Pneumonia,  80,  153,  162 
Polyorrhomeniiis,    55,    5^^.    59.    *^'' 
80.  153,  213,  249 


will    INDEX  TO  THE  DISEASES  REFKkKED  TO  IN  THIS  WORK 


Kiiiiil    l)isca»ie — 
Aciitf.   I  j4 
throinc  Tuba!    3,  23,  jr.,  31.,  34, 

4'.    3<'.    61,    80,     141,     144,     ly,. 

>.'5.<.    «54.    «37.    """.    2ii.   i2i3, 
ii7.   244 
Cliroiiic   Interstitial,    23,   30,   54, 

^'t.  fn,  150,  jtV) 
rripinia,   i  U> 
Septic  Diseases.  82 
Subaratlinoid  Il.i  niorrhage,   167 
SvpliiliN  43 


Syphilis     continutd 

Brain,   173 

Congenital,  155,   \f,y  \(„, 

See  alsii  iindor  C'irrhoitis. 
Tetanus,   24 

Thoracic  Aneurj-sm^  85 
Thronil)osis  of  Portal  Win,  30,  31, 

("■   I5.V   154.   IV>.  200,  213,  240, 

241 
Tubercli',   227 

.SVf  also  under  Peritonitis,   Pert- 
cardiiis,  and   Pleurisy. 


KRRATA 


I'.i^e  8,  line  17  from  top.  for  "  hysico-"  read  "physico-" 

I'aj^e  so,  Table  III,  for  "  single  "  read  "simple  " 

I'age  31,  line  5  from  top,  for  "  Hurians''  read  "  Hurian's" 

Page  32,  line  2  from  bottom,  for  "  togatose''  read  "  tagatose  " 

I'a^e  44,  line  14  from  bottom,  for  "  marrows  "  read  "  marrow  " 

I'age  51,  line  17  from  top,  omit  "in  " 

I'age  55,  line  8  from  footnote,  for  "  orhistid  in  "  read  "  or  histidin  ' 

I'age  64,  line  2  from  bottom,  for  "  H  +  "  read  "  H+  " 

I'age  68,  line  10  from  bottom,  for  "  oxidations  "  read  "  oxidative  ones  " 

Page  104,  to  formula  in  middle  of  page  add  "  atmospheres  " 

I'age  139,  line  2,  omit  "  fluid  " 

Page  173,  line  6  from  top,  for  122  read  r3i 

I'age  180,  in   the  Table,  for  "hydrops,   folliante"  read  "hydrops. 

folliculi " 
Pajic  182,  line  11  from  top  for  "  cetylalcohol  "  read  "cetyl  alcohol" 
Page  185,  last  line  of  Table  XX,  for  '•  trypisn  "  read  "  trypsin  " 
Page  206,  line,  1 5  from  top  for  "  Wideroe  "  read  "  Muller  " 
Page  234,  last  line,  before  Fig.  5  insert  '"  Plate  11 " 


STUDIES   IN   PUNCTURE 
FLUIDS 


INTRODUCTION 

CuNTENTs :  Objects  of  study  —The  caution  necessary  in  interpretmR 
results.  owinK  to  the  existence  of  important  variablci— The  insight 
into  metaliolit  pi. .cesses  attonleil  bv  the  chemistry  of  puncturc-Huids 
-  The  decomposition  procbicts  of  proteiil  may  be  either  initially 
present,  or  artilicially  produced  by  analytical  processes— The  main 
methods  of  physico-chemical  analysis— The  scheme  of  examination 
of  fluids — Cytodiagnosis. 

The  investigation  of  the  characters  of  puncture  fluids  may  l)e 
ina<le  with  two  objects:  first,  to  supply,  if  |)ossible,  the  means 
of  diagnosis  in  those  cases  where  the  cUnician  considers  an 
exploratory  puncture  indicated ;  and,  in  the  second  place,  to  supply 
a  gap  in  the  knowledge  of  the  chemistry  of  these  fluids.  Each 
of  these  aims  has  been  pursued  in  the  present  work  ;  and  though 
there  is  comparatively  little  to  be  said  about  differential  diagnosis 
that  has  not  been  said  before,  there  still  e.xists  a  need,  it  is 
thought,  for  bringing  together  the  various  diagnostic  }X)ints, 
both  for  reference  and  for  criticism. 

In  regard  to  the  first  aim,  the  scojje  and  limitations  of 
<liagnosis  call  for  primary  consideration.  As  it  has  been  with 
cytodiagnosis  for  the  past  eight  years,  so  it  has  been  for  a  mucli 
longer  jHjriod  of  time  with  chemical  differential  tests  of  puncture- 
fluids.  The  clinician  has  had  his  hojies  of  infallib'-?  means  of 
distinguishing  between,  say,  exudate  and  transudate  raised,  only 
to  find  tha*  exceptions  to  the  rules  arise  and  nullify  the  value 
of  the  pari.cular  test.  Or,  again,  he  finds  that  the  method 
advocated,  though  good,  is  yet  too  tedious  for  him  to  make  use 
of  it  during  routine  clinical  work. 

Both  of  these  adverse  views  need  modification,  for,  in  the 


2  STL'I)Ii:S    IN    rUNCTUKE-KLl'IDS 

fust  i.lace.  it  is  unlikrlv  that  there  will  ever  be  a  distinctive  test 
for  any  given  disease  that  can  he  furnished  hy  an  effusion  arising 
during  its  course,  simply  because  it  may  be  stated  as  a  funda- 
mental truth  that  there  is  nothing  fixed  and  immutable  in 
pathologv  ;  and.  in  the  second  place,  it  has  to  be  conceded  that 
thougti  there  are  manv  tests  which  are  tedious,  yet  a  rapidly 
performed  test  is  not  likeiv  to  be  as  reliable  as  a  more  thorough 
one,  because  the  very  thoroughness  will  strike  out  variables  in 
the  factors  which  contribute  to  the  diagnosis.  It  is  true  that 
a  complicate  proc<'dure  is  impossible  in  the  coarse  of  practical 
clinical  work,  but.  on  the  other  hand,  it  is  equally  true  that  the 
careful  study  that  can  be  made  in  suitably  equipped  clinical 
laboratories  is  worthy  of  pursuit. 

The  endeavour  to  add  to  the  knowletlge  of  the  composition 
and  constitution  of  puncture-fluids  has,  however,  been  the  main 
object  of  the  studies  which  are  recorded  in  the  i)res(-nt  work. 
It  is,  however,  readily  seen  that  it  is  impossible  to  carry  out  every 
form  of  analysis    in    a    given  fluid    simultaneously,  so   Ciat  it 
becomes  necessary  to  make  a  selection  of  the  particular  investi- 
gations desired  and  to  confine  oneself  rigidly  to  them  in  a  given 
series    of    specimens.     Other    forms    of     investigation     can    be 
ar-anged.  and  carried    out   in    another   series    of   fluids.     This 
has  been  found  the  only  way  to  cope  with  the  subject   in   the 
absence  of  co-workers— the  ideal  method  of  investigating  this 
s  .bject   where  autolytic  changes  or  decomposition-phenomena 
require    to    be    forestalled,     .t    is    necessary    to    mention    such 
difficulty  in  order  to  make  clear  that  in  no  one  fluid  which  one 
has  e.\amined  have  all  the  aspects  of  its  chemistry  been  gone 
into,  and  that  to  this  extent  an  absolutely  full  and  just  summing 
up  of  the  i)roperties  of  an  effusion  in  a  given  disease  or  given 
patient  must  fail.     On  the  other  hand,  it  must  be  remembered 
that  lor  the  purjioses  of  the  clinician  this  line  of  study  is  quite 
impossible,    and,    niore(n-er,    exjiloraiory    jiuncture    often    only 
allows  a   few  cubic   centimetres   of  fluid   to   be   submitted   for 
examination. 

It  will  be  found  from  the  >ubsequent  pages  that  the  attempt 
has  been  made  to  comi)el  the  physico-chemistry  to  supplement 
the  c'n'inistry  of  the  puncture-fluid.  This  has  been  applied,  as 
i>  vscii  kiuiwn,  h\-  several  renowned  scientists,  to  the  examination 
(if  bloini  and  iiriitc,  but  so  far  as  can  be  made  out,  there  has  been 


'%«."}f.' 


INTRODUCTION  3 

no  attempt  hitherto  to  apply  the  principle  to  the  study  of  the 
ordinary  i^uncture-fluids.  It  is  believed,  however,  that  such 
an  application  of  the  newest  lines  of  study— those  of  ionic  con- 
stitution— will  afford  an  insight  into  the  metabolic  processes  of 
thos'  diseases  which  are  associated  with  the  pouring  out  of 
fluid. 

Not  only  this,  but  the  attempt  has  been  made  to  compel 
chemistry  and  physico-chemistry  together  to  afford  an  ex- 
l)lanation  of  the  concordance  or  discordance  which  exists  between 
the  diagnosis  hitherto  made  by  their  aid,  and  the  actual  nature 
of  the  disease  ;  this  has,  however,  frequently  led  one  into  the 
subject  of  the  pathology  of  metabolism,  a  subject  which  must 
of  necessity  be  left  in  the  background  in  the  following  jiages. 
Still,  it  must  i)e  reasonable  to  su])pose  that  the  study  of  the 
Huids  which  are  poured  out  must  give  great  aid  not  only  to  the 
pathology  of  metabolism  of  a  given  disease,  but  must  assist  in 
forming  a  diagnosis  of  the  disease.  To  illustrate  this  idea,  the 
deviations  from  normal  metabolism  which  obtain  in  disease  of 
the  liver  may  be  referred  to.  They  will  dej)end  to  a  large  ex- 
tent on  the  nature  of  the  disease  with  which  the  liver  is  affected, 
and  more  than  this,  these  changes  will  be  different  according  to 
whether  the  disease  is  jirimarily  one  of  the  liver,  or  primarily 
one  of  the  heart.  Each  of  these  is  bound  to  result  in  a  different 
succession  of  changes  from  those  due,  for  instance,  to  renal 
k  dise;ise,  and  the  chemical  composition  of  the  fluid  poured  out  will 
ibe  corresix)ndingly  different.  The  excessive  amount  of  chlorides 
fpresent  in  nephritic  effusions  as  compared  with  back-pressure 
[effusions  instances  the  correctness  of  this  contention.  Then, 
again,  the  investigation  of  the  various  decomposition  products 
of  proteid  that  occur  in  an  effusion  will  afford  a  not  mconsiderable 
;  light  on  the  catabolic  changes  met  with  in  the  disease  with  which 
the  effusion  is  associated. 

To  consider  for  a  moment  another  example  of  this  j)rinciple. 
The  fluid  in  a  case  of  iKMitoneal  carcinomatosis  presents,  on 
cytological  examination,  desquamated  carcinoma  cells,  some  of 
which  are  living  and  some  necrotic.  1  hcse  cells  have  a  s{)ecialised 
form  of  metabolism,  though  the  only  known  fact  about  them  is 
that  their  proteid  is  essentially  different  in  nature  from  normal 
cell-proteid.*  This  difference  in  ronstitutinn  mast  invoivo  a 
*   Bergell.     See  also  Hottmann,  Mihich.  mcd.  Woch..  46,  1907. 


STUDIES  IN   rUNCTURE-FLUlDS 


difference  in  the  jiroducts  of  brealcdown  of  the  proteid,  though 
exactly  what  the  differences  in  the  two  series  of  cases  (healthy 
metabolism,  and  carcinoma-cell  metabolism)  may  be,  and  where 
they  are  to  be  located  in  the  configuration  of  the  proteid  mole- 
cules, is  quite  unknown  at  the  present  time.  The  presence  of 
both  living  and  dead  cells  too,  not  only  in  the  fluid,  but  all  over 
the  surface  of  the  jieritoneum,  means  that  these  metabolic 
products  occur  in  the  fluid  which  they  have  caused  to  appear, 
and  a  chemical  study  of  such  a  fluid  must  afford  an  insight  into 
the  metabolic  changes  of  carcinoma  celMife.  Not  only  this, 
but  there  is  the  question  of  ferment  action  to  be  considered. 
There  are  ferments  in  the  peritoneal  fluid  of  carcinomatosis 
cases,  which  may  be  specific,  and  are  of  importance,  because 
they  have  actuated  this  particular  form  of  metabolism.  We 
must  not  forget  meanwhile  that  the  whole  of  the  serosa  is  not 
one  mass  of  ])rolilerating  carcinoma.  There  are  extensive  areas 
in  which  there  is  no  carcinoma,  and  the  cliemicai  composition 
will  de}>end  to  some  extent  on  the  normal  processes  of  life  of 
these  cells,  and  on  their  permeability-phenomena.  That  is  to 
say,  we  shall  meet  with  the  resultant  of  two  series  of  ])rocesses 
— quite  a  different  matter  from  having  only  a  single  factor  to  deal 
with.  If  reference  be  made  to  the  possibility  of  a  diseaseii 
condition  of  the  hitherto  intact  serosa  following  the  changes 
produced  in  the  organism  as  a  whole  (cachexia,  etc.),  we  shall 
at  once  see  clearly  that  there  are  so  many  factors  that  it  would 
be  remarkable  if  all  diagnostic  rules  in  the  case  of  carcinomatous 
puncture-fluids  were  always  infallible.  Perhaps  it  is  more 
important  to  suggest  that  herein  lies  the  means  of  justly  appre- 
ciating the  facts  on  which  one  can  base  a  diagnosis,  for  by  bearing 
the  variables  in  mind,  one  may  attempt  to  secure  more  accuracy 
in  one's  opinion. 

These  considerations  have  been  gone  into  at  such  length, 
because  it  is  felt  that  there  is  an  undue  tendency  to  expect  such 
investigations  as  are  recorded  in  the  following  pages  to  enable 
a  positive  and  certain  diagnosis  to  be  made  as  to  the  nature  and 
origin  of  an  outpouring  of  fluid.  It  is  not  so.  We  must  say, 
"  such  and  such  a  substance  (of  which  the  tests  are  given)  is 
more  abundant  in  a  certain  percentage  of  cases  of  this  class  of 
effusion  than  it  is  in  another  class  of  case."  Even  these  limita- 
tions do  not  deprive  the  methods  of  all  utility,  for  clinical  symp- 


INTRODUCTION 


5 


toms  often  help,  and  just  as  pros  and  cons  have  to  be  weighed 
in  ordinary  clinical  diagnosis,  so  they  frequently  have  to  be 
wciL'hed  in  clinKul  pathological  diagnosis. 

Attention  must  be  directed  also  to  the  errors  that  may  arise 
from  the  difference  in  the  structure  of  various  proteids.  Many 
proteids  contain  the  same  fundamental  substance  as  an  mtegral 
part  of  their  molecule.  The  following  table,  which  has  been 
•ibrulged  for  the  present  purpose,  from  the  valuable  work  of 
Gustav  Mann  (Chemistry  of  the  Proteids,  1907),  will  illustrate 
what  is  meant.  We  see,  for  instance,  that  glycocoll  forms  a 
part  of  the  molecule  of  serum-albumen,  of  serum-globulin,  of 
hetero-albumose,  and  of  keratin  ;  that  tyrosin  occurs  m  serum- 
albumen,  in  protalbumose,  in  Bence-Jones  proteid,  and  in 
keratin  ;  that  tryptophane  is  only  present  in  kerafn  (in  this 
tal)le)  and  so  on.  Our  chemical  analysis  may  re  al  the  pre- 
sence  of  all  these  bodies,  and  of  course  it  would  only  be  possible 
bv  a  careful  separation  of  each  of  these  bodies  to  say  to  which 
the  derivative  is  to  be  ascribed.  If  we  find  tryptophane  or 
tyrosin  in  a  puncture-fluid,  for  example,  we  cannot  be  sure  that 
it  was  there  beforehand,  or  whether  the  analysis  has  resulted 
in  its  being  split  off  from  a  proteid  containing  it. 


^i^ 

Serum- 
'  alliuiiit-n. 

1 

Seruiii- 

Hlobulin. 

Hetero- 
albumose. 

Prot- 
albutnuse. 

Bencc- 

Jonei 

proteid. 

rrot.-imin 
(Slurinl 

Honi- 
keratin. 

GlvcocoU 

+ 

3-52 

+ 

0 

0 

0-34 

Alanin 

+ 

2-22 

Leucin 

18-7 

+ 

+ 

+ 

J8-3 

Phenylalanin 

+ 

3-H4 

+ 

0 

30 
3-6 

Prolin 

+ 

2-76 

Glutaminic    acid 

+ 

2-20 

+ 

14 

Aspartic  acid 

■t- 

2-54 

0 

2"> 

6-8 

570 

4-58 

Cystin 

Serin 

1-2 

1-51 

Tyrosin 

■2-7 

,     , 

0 

+ 

+ 

0 

Lvsin 

3-5 

3-5 

^ 

12 

Histidin        . .      .  . 

2-2 

2-2 

12-9 

Arginin 

4-9 

49 

58-2 

2-25 

Tryptophane 

0 

0 

Ammonia     .  . 

175 

0-8 

0-8 

1-6 

0 

Ami  no  valerianic 

acid 

.     . 

! 

' 

•• 

y? 

Glucosamin 

1 

0 

0 

0 

The  table  reveals  a  further  fact,  namely,  that  the  amount 


STUDIES  IN   PUNCTURE-FLUIDS 


of  each  derivative  varies  according  to  the  different  proteid. 
Thus,  if  we  find  seven  parts  of  lysin  we  shall  not  know  whether 
this  means  that  it  has  all  been  derived  from  equal  parts  of 
hetero-alhumose  or  protalbumose,  or  whether  it  is  a  proportion 
characteristic  of  some  other  i)roteid  not  included  in  this  table. 
We  might  even  say  that  we  cannot  be  sure  that  the  numbers  in 
this  table  do  really  characterise  the  particular  proteid  under 
which  it  is  placed.  But  assuming  the  table  absolutely  correct", 
and  assuming  that  our  analysis  is  correct,  it  is  evident  that  by 
slightly  altering  the  relative  proportions  between  one  deiivative 
and  another  we  shall  really  be  having  a  different  proteid  before 
us.  Such  slight  differences,  which  involve  us  in  endless  per- 
mutations and  combinations,  would  afford  an  e.xplanation  of 
the  biological  distinctions  that  obtain  between  one  proteid  and 
another,  between  fish-albumen,  and  mollusc-albumen  ;  not  to 
mention  the  possibility  that  stereo-isomeric  variations  might 
result  in  still  more  refined  and  none  the  less  absolute 
distinctions. 

To  sj^eak  of  such  possibilities  as  these  is  but  to  touch  on  a 
fringe  of  the  difficulties  thai  arise  in  interpretation  of  results 
of  analysis,  and  would  at  first  sight  deter  one  from  ever  attempt- 
ing an  opinion  in  a  case.  Fortunately,  however,  there  remain 
many  tests  of  easy  application  which  will  help  the  clinician  to 
form  his  diagnosis  in  a  case  associated  with  effusion.  Even  in 
spite  of  all  the  chances  of  error  which  have  been  indicated, 
these  tests  preserve  their  utili  y,  and  the  fact  that  failure  may 
sometimes  arise  should  not  be  allowed  to  relegate  them  into 
the  background  ;  and  we  may  hope  that  with  time,  a  better 
knowledge  of  the  details  to  which  reference  has  been  made  will 
explain  the  cause  of  the  failure  of  such  tests  in  some  cases,  ^nd 
enable  a  better  inter})retation.  with  more  frequently  successful 
diagnoses,  to  be  made. 

The  statement  may  be  made  that  a  transudate  with  decided 
characters  may  be  certainly  distinguished  from  an  exudate 
possessing  decided  characters.  The  border-line  cases,  or  the 
cases  in  which  inflammation  sujx^rvenes  on  transudation,  are 
those  which  are  resjwnsible  for  the  small  utility  which  chemical 
diagnosis  and  cytodiagnosis  have  possessed.  But  if  we  re- 
member that  the  microscojje  diagnosis  of  innocent  tumours 
from  malignant  tumours  also  fails  when  we  come  upon  the 


INTRODUCTION  7 

border-line  cases,  we  shall  see  that  there  is  no  more  justification 
for  condemning  the  one  method  of  study  than  the  other 

In  pursuit  of  the  studv  of  puncture-fluids  it  has  therefore 
been  borne  in  mind  that  we  shall  learn  far  more  from  the  failures 
,n  diagnosis  than  from  a  long  succession  of  successes  and  the 
endeavour  to  find  an  explanation  for  the  failures  will  lead  us 
deeper  and  deeper  towards  the  solution  of  the  ultimate  problems 

of  metabolism.  .  •  .   v,        k«„„ 

Turning  now  to  the  actual  methods  of  study  which  have  been 
employed  m  the  course  of  this  work,  it  will  be  seen  that  an 
ordinary  chemical  examination  has  been  supplemented  by  a 
physico-chemical  examination  of  the  puncture-fluids,  with  the 
object  of  obtaining  an  analysis  of  the  grouping  of  the  ions  present 

in  anv  givtn  case. 

\  consideration  of  the  details  of  the  ionic  theory  on  which 
so  much  of  biochemical  research  is  based  comes  more  under  the 
domain   of    theoretical  chemistry.        A    brief   account   of    this 
lonic  theory,  as  well  as  of  the  theories  on  which  cryoscopy  is 
based    have    however,  been  included  for  the  sake  of  complete- 
ness • '  but  it  has  been  felt  desirable  that  the  details  of  the  method 
of  i)erformmgboth  cryoscopy  and  electro-conductivity  beomitted. 
The  question  of   the   significance  of  the  concentration  of  the 
hydrogen  ions  as  affording  an  understanding  of  the  meaning  of 
the  term  acid  and  base  has  been  entered  into,  in  order  to  give 
an  explanation  of  much  ^yecia.\  work  that  has  been  performed, 
especially  in  Italy,  and  to  indicate  where  such  conceptions  may 
be  erroneous.     The  fact  that  hydrogen  ions   possess  practically 
the  same  concentration  as  the  hydroxyl  ions  in  puncture-fluids 
does  not  really  alter  the  tact  that  they  have  more  basic  pro- 
perties than  acid,  that,  indeed,  they  are  not  really  functionally 
neutral  fluids. 

The  mention  of  the  term  cryoscopy  inevitably  calls  up 
visions  of  a  vigorous  controversy  between  exjwnents  of  the 
theory  that  renal  disease  is  diagnosable  by  its  aid  and  the 
opponents  of  the  theory.  The  fact  must  be  admitted  that 
cryoscopy  was  unduly  advoci  ted  for  a  puri)ose  for  which  it  is  un- 
suitable, since  the  estimation  of  the  working  power  of  the  kidney 
cannot  be  based  solely  on  the  molecular  concentration  of  the 
urine,  because  the  osmotic  work  iKjrformcd  by  the  kidney  con- 
»  See  Svante  .\rrhenius,  Theories  of  Chemistry,  1907. 


8 


STUDIES    IN    ITNtTUKIMLUIDS 


sists  of  tlio  osmotic  work  ol  wattr-sccrction  plus  that  of  water 
absorption  plus  that  of  seloctive  a<  tion  on  the  constituents  of  the 
blood,*  a  (latum  which  cryoscopy  fails  to  supply.  However, 
the  method  is  useful  as  affording,'  a  value  for  the  osmotic  con- 
centration of  a  ])unctiue-tluid  which,  by  association  with  a 
determination  of  the  electro-conductivity,  or  a  determination 
of  the  substances  impermeable  to  red  cells  (Hamburger's  method), 
enables  us  to  chusify  the  varieties  and  amounts  of  the  different 
kinds  of  ions  present.  The  determination  of  the  relations  be- 
tween the  amount  of  chlorine  ions  and  of  the  achloridi  ions  to 
the  substances  for  which  red  cells  are  imjiermeable,*  is  valuable 
for  deciding  on  the  molecular  constitution  of  various  fluids. 
Such  a  study  demands,  of  course,  considerable  apparatus, J 
unnecessary  for  the  clinician,  it  is  true,  but  valuable  to  the 
biochemical  student  to  exactly  the  same  extent  as  is  the 
microscope  to  the  histologist,  with  the  difference  that  much 
more  care  and  practice  are  necessary  before  the  hysico-chemical 
api^aratus  can  be  effectively  used.  § 

Tiie  scheme  of  chemical  analysis  which  is  submitted  is  the 
result  not  only  of  practical  experiments  but  also  of  study  of  the 
various  methods  which  have  been  advocated  by  eminent  chemists. 
It  was,  hovvever,  felt  that  a  combination  of  the  different  methods 
of  separation  of  the  proteids  might  be  advantageous,  and  an 
abstraction  of  the  methods  described  in  many  numbers  of  the 
Zcitschrijt  fiir  physiologische  (hcmie  should  be  found  convenient, 
especially  to  clinicians  who  have  not  the  time  to  turn  up  the 
volumes  needed.     The  confirmatory  tests  which  are  given  are 

*  Pauli,  Physical  Chemistry  in  Medicine,   1907. 

t  The  dilference  I)et\veen  the  molecular  concentration  as  given  l)y  the 
cryoscopic  method  and  that  given  by  Hamburger's  blood-corpuscle  method 
gives  the  concentration  of  the  bodies  for  which  red  c  ells  are  permeable, 
and  those  very  bodies  are  all  the  most  important  products  of  ptoteid 
cataholism. 

X  All  this  special  apparatus  barely  costs  as  much  as  one  of  the  better 
micioscopes. 

§  The  physico-chemical  methods  of  examination  may  be  grouped  under 
the  following  headings  : 

1.  The  determination  of  the  total  osmotic  concentration  of  a  fluid. 

2.  The  determination  of  the  concentration  of  the  chloride  electrolytes 
in  the  fluid. 

3.  The  doternuudlion  ul  Ihe  acliloiiUt-  electrolytes. 

4.  The  determination  of  the  concentration  of  the  non-electrolytes. 

5.  The  determination  of  the  concentration  of  the  hydrogen  ions. 


INTRODUCTION 


also  a  compilation  from  the  literature,  but  it  has  been  felt  that 
the  many  confirmatory  tests  desirable  Ix-fore  stating  definitely 
that  a  given  substance  is  present  should  Ix?  collected  together. 
The  fluids  which  have  come  under  consideration  have  been 
classified  as  foil  -ws,  and  are  dealt  with  in  the  same  order  : 

1.  The  fluiils  which  occur  in  the  large  serous  cavities  : 

(<()  Pleural.     Exutlations,  transudations,  pus. 
(/()  Peritoneal.     The  same  varieties. 

2.  The  fluids  which  occur  in  the  small  serous  cavities  ;  such 

as  the  joint-effusions. 
The  ccrebro-sjtinal  fluid. 

Fluids  derived  from  cysts  :  (<0  intra-abdominal ;  ovarian  ; 
pancreatic  ;  rare  cysts  ;  (h)  in  other  regions  of  the  Iwdy. 
Each  of  these  classes  of  fluids  will  be  studied  from  their 
chemical  and  their  ]ihysico-chemical  aspects. 

Finally,  a  reference  will  be  made  to  the  cytological  characters 
of  various  puncture-fluids,  as  the  cellular  elements  which  are 
present  in  an  effusion  have  some  bearing  on  its  chemical  com- 
position, and  are  probably  largely,  if  not  entirely,  responsible 
for  the  ferments  which  it  may  contain. 


4- 


SFXTION    I 

THE   CHEMICAL   EXAMINATION   OF 
PUNCTURE-FLUIDS 


t'oNTKNTs  :  rrfliininary  remarks  —  Ditticultit-s  attachfil  to  the  .•.nalyj'is 
of  thiiils — I'recipitatiou  of  allmmen  l>y  mastic,  etc. — .Vdsorption — 
Scheme  for  analysis  of  puncture-Uuids.  (A)  I'rehminary  processes. 
(B)  Separation  of  tlie  v;h)l)iihns — Allmmen — (llohulin — .Mhumoses 
and  peptone^  ~  Monaminoacids — .\mmonia — Hydrolysis —  Sugars — 
I'lirins  and  urea.  ((')  Dianiinoacids — Residual  nitrogen.  (D)  The 
glycoiiroteids  ;  p>eudo-nuicm,  its  jiroperties  and  reactions  ;  para- 
mucin  ;  svnovin  —  Lecithin,  its  importance.  ti)n--titution,  allies,  and 
symbiotic  substances,  an<l  methods  of  analy  .is — The  diazo-reaction 
—  The  c-naphthol  reaction  —  Khrlich's  glucosamine  reaction — Trypto- 
j)hane  —  Pigment — The  inorganic  constituents  of  piincture-tluids — 
l"erments.   their  detection,  their  occurrence,  and  their  importance. 

The  groat  stritlos  which  physiological  chemistry  has  made  during 
recent  years  enable  us  to  obtain  a  far  ileeper  insight  into  the 
processes  of  pathological  metabolism  than  was  before  jwssible. 
The  flood  of  light  which  has  been  thrown  on  tl  >  constitution  of 
proteid  matter  by  such  an  eminent  organic  chemist  as  Emil  Fischer 
has  jierhaps  furnished  the  most  striking  increase  in  our  know- 
ledge not  only  of  pathological  chemi^try  but  of  pathology 
as  a  whole.  The  application  of  this  knowledge  to  a  study  of 
the  pathological  effusions  in  \arious  parts  of  the  body  seemed 
a  jiromising  field  of  research,  esjwcially  as  these  fluids  can  be 
made  to  afford  interesting  evidence  of  the  jjrocesses  of  break- 
down of  proteiil  in  disease.  As  L'mber  *  has  said,  an  effusion 
into  the  jieritoneum  is  an  accumulation  in  a  sterile  reservoir  of 
the  intermediate  retrograde  i)roducts  of  proteitl  metabolism 
which  are  preserved  intact  for  a  considerable  length  of  time 
owing  to  the  processes  of  absorption  being  e.-cceedingly  slow. 

*  1  he  references  to  the  original  articles  who>e  autliors  are  quoted  are 
collected  into  a  separate  bibliography  for  each  section  and  placed  at  the 
end  of  this  book. 

lO 


TlIK  CHEMICAL   EXAMINATION   OF   PUNCTURE-H-UIDS 


I  [ 


The  first  problem  which  presents  itself  is  that  of  devising  a 
Mutable  mellwd  of  analysis  wh.ch  shall  enable  the  various  Ixxhes 
iik.lv  to  be  j.resent  in  a  ^iven  puncture-flui.l  to  be  detected, 
md  '  if  ix.ssible.  estimated  quantitatively.     There   is.  however, 
the  <lithcultv  that  in  some  cases  there  is  only  a  very  small  amount 
ot  fluid  available  for  analysis,  so  that  methods  have  to  be  found 
wluch  will  enable  as  many  of  the  imi^rtant  substances  as  i)ossible 
to  be  searched  for  in  the  successive  fractions  obtained.     There 
is  aNo  the  dithcultv  that  the  results  obtained  are  awaited  by  the 
chnician   who  does  not  wish  to  delay  with  his  final  diagnosis  any 
l„nger  than  necessary.     Moreover,  the  sooner  the  analysis  can 
be  completed  the  less  chance  there  is  for  autolytic  decomiwsition 
of  the  Huid  to  take  place. 

Of  all  the  constituents  of  puncture-fluids  the  most  abundant 
IS  alhuwcn.  ami  the  interest  attached  to  this  substance  is  more 
than   that  as  to  its  mere  quantity,  since,  in  the  first  place,  it 
may  become  involved  in  autolytic  or  in  fermentative  changes 
which  lead  to  the  production  of  dissociation  products,  while,  in 
the  second  place,  it  is  resix)nsible  for  certain  imiwrtant  physical 
projierties  that  such  fluids  manifest.     It  is  jx-rhaiis  too  much  an 
exaggeration   to  speak  of  the  i)critoneal  fluid,  for  instance  in 
tuberculous    i)eritonitis.   as   reaUy  an   albiiminoiis  solution    cf 
various  substances,  but,  on  the  other  hand,  one  cannot  fail  to  be 
struck  by  the  volume  of  the  coagulum  when  such  a  fluid  is  boiled 
in  the  presence  of  acetic  acid.     On  this  ground  it  is  not  altogether 
incorrect  to  sj^eak  of  most  puncture-fluids  as  proteid  solutions, 
an    asiK'Ct    which   will  emphasise  the  essentially  colloidal  pro- 
perties of  these  fluids,  that  are  so  imjiortant  to  realise  when 
forming  a  conception  of  the  part  which  they  play  in  pathological 
metabolism. 

Not  only  this,  but  the  albuminous  nature  of  the  fluid 
(90  per  cent,  by  volume  in  many  exudates)  justifies  the  statement 
that  exact  quantitative  analysis  of  a  puncture-fluid  is  imi)Ossible, 
since  the  removal  of  the  albumen  destroys  its  essential  nature, 
apart  from  the  fact  that  its  removal  disturbs  the  osmotic  and 
'.onic  relations  of  the  other  constituents.* 

To   remark  "  remove    the  albumen   by   boiling,"  especially 
if  there  be  much  albumen,  is  merely  to  ignore  all  these  difficulties. 
♦  This  aspect  of  tlie  sul>ject  will  call  for  further  comment  on  a  subse- 
quent page. 


13 


STUKIES   IN    PrNCTlRE-KLL'IDS 


\\V  liavi'  tlu-n  to  >tii(ly  tin-  pioinitics  ot  our  fluids,  not  from 
\hv  staii(liM)iiit  of  a  w.ittr-basis,  Iml  from  the  stan(l]X)int  that 
the  proptrtics  arc  those  posM'ssid  l)y  colloids  towards  electrolytes 
ill  ((()  ( olioidal  and  (h)  in  watery  solution.  We  have  also  to 
inar  m  mind  the  fact  that  the  proteids  present  in  these  tluitls  are 
the  hearers  of  electrical  charf,'es.  in  virtue  of  the  fact  that  electro- 
lytes lire  present,*  ami  that  the  process  of  boiling,  or.  indeed, 
any  method  of  removal  of  proteid  from  the  solution,  destroys  or 
alters  the  electrical  charges,  and  thus  interferes  with  physico- 
cluiuicid  pn)i)erties.  hf^ides  allowinf,'  free  ])lay  for  new  associa- 
tions to  take  place. 


Mkthods  for  Removing  Albumen 

^h•re  mcntinn  of  the  familiar  processes  of  removal  of  albumen 
from  a  Huid  is  sufficiint,  and  those  which  are  advocated  for  the 
sti'dv  of  puncture-tiuids  are  given  in  Tables  A  to  D.  But  an 
important  method  of  removal  of  albumen,  devised  by  Michaelis 
and  Kona,  calls  for  more  careful  consideration,  since  it  makes 
use  of  the  i)henomcnaof  adsorjition  for  separating  off  the  albumen. 
These  authors  ])oint  out  the  fact,  already  laid  stress  on,  that  the 
ordinary  methotis  of  de-albuminisation  of  a  fluid  are  unsatis- 
factory for  many  purposes,  since  boiling  damages  the  fluid, 
alcohol  is  undesirable  in  subsequent  processes,  and  salting  out 
introiluces  a  new  element  altogether.  Starting  with  the  fact 
that  colloids  of  opposite  electrical  sign  will  cause  one  another  to 
separate  out,  provided  the  two  bodies  are  present  in  just  sufficient 
quantity,  the  two  authors  mentioned  hit  upon  the  use  of  a 
watery  solution  of  mastic  which  should  e.\ert  this  electrical  effect. 
They  found  (i)  that  if  a  small  quantity  of  mastic  be  added  to  a 
large  proportion  of  albuminous  solution,  the  mastic  would  not 
be  separable,  owing  to  a  protective  action  exerted  on  it  by  the 
albumen  ;  (i)  that  if  the  i)roportions  of  the  mi.xture  were  re- 
versed the  ojjposite  held  good.  The  explanation  of  the  pheno- 
menon is  afforded  by  the  ultra-microscoi^e,  which  shows  the 
])articles  of  albumen  in  combination  with  particles  of  mastic, 
in  such  manner  that  each  i)article  of  mixture  consists  of  mastic, 
plus  albumen.     If  there  \x  excess  of  the  latter,  it  becomes  possible 

•  .Mbumen,  pseudo-globulin,  and  euglobulin  show  no  electrical  charge 
in  the  absence  of  electrolytes  (Pauli). 


THE  CHEMKAL   EXAMINATION   OF   PUNCTlKE-l  LLII.S      13 

,,„  ,ach  particle  of  mastic  to  »>e  completely  envelo,>e.l  by  alhu- 
,       Tic   surface   tens.on  will   thus  otrly  have  ettect   <.n   the 
:„.n  ar..!  n<.t  on  the  n.ast.c.     Tins  -"'«;'«•--;!! 
,„„,,,  n,ast,c  has  been  ad.lecl  that  .t  cannot  all  be      n.askul. 
,,„a  ,a  that  iH,int  the  whole  of  the  albumen  w.ll  separate  out. 
The  methods  which  they  advocate  are  :  .       ,     ,    ,   ■ 

Method    I  -A   lo-per-cent.  s<,lution  of  mast.c  m  alcohol  is 
suddudv  d,h.ted  wilh  tw.ce  its  bulk  of  water,  an.l  the  result.n^ 
.n.x.ure  .s  ad.led  to  the  fluid  to  be  de-albumm.sed  u,    In   pro- 
,x,rtion  of   lo  parts  n.astic  mixture  to   i  of  l^u.d  ;    z  pa  b,  o 
lo.,.'r-cent.  acet.c  aci.l  are  then  aclde<l.  m  order  to  ac.d.fy    h 
,„,xtare.     In  half  an  hour  a  sim.lar  (juantity  of  mast.c  .s  ad.lul 
.^ra.luallv.  and  ac.dified  bv  a  further  similar  .p.a.it.ty  of  the 
acet.cacul ;  .'-  5  partsof  lo-per-ccnt.  ,na«..esu.msu  ,.hate  are  now 
added  giaduallv  until  a  definite  ,-.rec.p.tation  takes  place    and 
after  a  short  ,x>r,od  of  digestion  in  a  tep.d  water-bath,  the  flu.d 
xv.ll  be  found  to  filter  easily  and  leave  a  completely  albumen- 
free  filtrate.     In  the  event  of  the  removal  Ixnng  .ncomplete, 
a  third  addition  of  mastic  is  indicated. 

MclhoJ  B  -50  cc.  of  fluid  are  diluted  with   12-15  parts  ol 
Nvater.  and  as  much  acetic  acid  is  adde.l  as  will  clear  up  the  tur- 
bidity     To  every  100  cc.  of  fiuid  20  gm.  of  kaol.n  are  added  in 
four  or  five  instalments,  vigorous  shaking  Ix-ing  carried  out  during 
this  process.     The  filtrate  will  now  Ik  quite  free  of   albumen. 
This  method,  published  in  July  1907.  obviates  the  necessity  .n 
method  A  of  first  getting  rid  of  excess  of  albumen  by  a  prel.m.nary 
alcohol  piecipitation,  wb.ich  renders  method  A  applied  to  fluids 
rich  in  albumen  of  no  advantage  over  former  methods  of  de- 
albuminisation. 

The  filtrate  from  these  methods  contains  monammoacids, 
diaminoacids,  and  jwlyi^-ptids  ;  and  i'  is  necessary  to  remember 
that  there  is  present  in  this  filtrate  a  nitrogen-free  sulistance  of 
unknown  nature,  soluble  in  water,  which  will  come  down  with 
phosphotungstic  acid  unless  an  excess  of  tannin  lie  added  to 
prevent  its  precipitation  by  phosphotungstic  acid. 

The  precipitate  will  contain  albumen,  globulin,  and  albumose, 

but  no  sugar. 

Pkkardt's  Method  of  Removing  Albumen.— 200  cc.  of  fluid  are 
boiled  for  three-quarters  to  an  hour  ;  then  add  dilute  acetic  acid, 
drop  by  drop,  till  just  acid.    Heat  three-quarters  of  an  hour  in  a 


'4 


STII»IES  IN    lUNCTUkK-KLLins 


current  of  stoaiii.  lioil  tlu'  iv^ulm'  witli  water,  iitul  sqmrze  it  out 
in  a  han<l-pr»'s>..  Tlit'  mixt-d  ftltratt-s  are  hitereil  while  hot  and 
the  residue  washi-il  with  hot  water.  The  filtrate  wil!  Iw  abso- 
lutely albumen- tree. 

A  climml  inclliihl  ot  estiniatinj,'  albumen  has  been  devised 
by  Deyc  ke  and  ll)rahim.  J  cc.  of  fluid  arc  mixed  with  j  cr.  of  n  '5 
soda  (forms  a  Miltiblc  alkali-.ill>uminate).  ami  is  then  made  up 
with  soda  to  loo  (c  in  a  tlask.  J5  ic.  of  this  diluted  solution  are 
placed  in  a  flask  "f  o  cc.  capaeity.  and  2  jcc.  of  jjlaiial  acetic 
a(i<l  and  jo  i  .  ot  iK)tassio-mercurio  iodiiK-  solution  are  added. 
The  vohiiiu'  is  made  up  with  distilled  water.  The  jMecipitated 
merniry  ali)iiminate  is  filtered  off  and  100  cc.  of  filtrate  treated 
with  10  cr.  |M)tassium  cyanide  and  lo  cc.  ammonia.  The  amount 
of  unaltered  ( vanide  is  estimated  by  titration  with  n  20  silver 
nitrate. 


.\i)S(iKiTi(i\.  — liefoie  proceeding  with  tlu*  actual  methods  of 
analysis  there  remains  one  more  theoretical  consideration,  namely, 
the  effect  of  removal  of  proteid  oh  the  electrolyte  contents.  It  will  Iw 
seen  that  considerable  importance  is  being  attached  to  the  amount 
of  electrolytes  present  in  exudates  as  compared  with  transudates 
{Section  I\'),  and  the  question  arose  not  only  as  to  the  most 
simple  method  of  analysis  but  as  to  whether  there  was  any 
source  of  error  likely  to  arise  in  any  of  the  methods  adojjted  for 
removing  the  albumen.  It  is  well  known  that  if  albumen  be 
treated  with  hydrochloric  acid  a  certain  amount  of  the  latter 
will  enter  into  combination  with  the  albumen,  and  cannot  te 
detected  in  the  hltrate  after  boiling  to  remove  proteid.  The 
albumen  is  considered  to  have  adsorbed  some  of  the  CI. 


V  I 


f 

i     i 


What  IS  to  lie  txaitly  micliT^todil  hy  the  trriil  "  adsorptitjil  '  it  isdilii- 
ciilt  ti)  say.  and  this  word  has  Ik-cii  iiixokiil  i)<.-rha|)s  to  gi\i-  an  apparent 
i-.xplanatioii  lor  phcnoniina  which  wort-  not  correctly  nndorstood.  Thns 
it  IS  ailinittcd.  even  hy  Ostwald.  that  tliere  is  no  sharp  tlitference  l)ftwecu 
chemical  allinity  and  adsorption.  In  lacl,  when  one  comes  to  consider  it 
it  IS  olten  really  very  ditlicult  to  be  sure  that  the  nnion  between  two  bodies 
IS    phvsical    and    not    chemical. 

The  question  at  issue  which  renders  it  desirable  to  discuss 
adsorption  at  all  is  as  to  whether  the  chlorine  met  with  in  a 
puncture-fluid   is    "  free  "   or    "  combined  "    with    the   proteid. 


w.«. -Tr;;::;:;'""-:-":'---"^^^^ 

„,.allyunattacheatoth.    '^"  '     ;        ^.J^,,  ost.maU-a.  say.  by 
,..  un..w  t.u.   total   a.nou      o    . I  h      i^ ^  -     ^^^^^^^^    ^^^    ^^^.    ^^ 

•"""^■^="""    ,":^"r^-uU       H     >rot...l   .loos   hoUl   so.luun 

,.,,,,„„,,  ,„  „s  ■"'■^'^*^''";'"V'  ,'  us.s  will  ..nlv  ropn-sent  that 

,H,ittoiioi  tJu- N.Hl^^'»"^'"        ,h..  roiirulum.     \\V  shouhl  say. 
Lv,nK  passo.l  '"evocahlv  ,nt  ,  th.  u  ^  Urn         ^^^^^^^^     ,  ^.^^ 

w.th  S.  M/.,  tlut  sonv  of  th.  (  1  .>       >    ";>     > 

„,..  pn.t...l.  ami  tlu-     ^    >s    -  accuU-ntal. 

,„,,..,   ,1».   very  --.mo  M"-"""    »""'«''   ,^      „   ..hvs.cal  coml.t.on  ol  ttu- 
,.,,Ma,K.>  m  s.rum  ur.  ....1.1  >n  -  '"^         ";^  j^,.,;  „^  ,„,.„„,     ■,.,  s.,lvo  the 

VV...le  B-ivhss  acH-s  at  U-n.-th  into  the  effect  of  Congo  reel  on 
While  Bay hssM  ^j    adsorption,  we 

nUer-pa,K>r  -/"  "^;^'tu  ngs  of  others,*  who  ins.t  that 
rece.ve  a  rebuH  f  om  ^  J?  ^  ^  -j-j,^.  ^^^„,,  author  clescr,lx>s 
.he  reaction. sr^lly^^.^u^<-  hut  in  the  ex^H-nment. 
the   a.lsorpt.o..  u.   .  a  .      >    ^  ^^^  ^^^^^  ^^  ^^^^^^^ 

„arrate.l  U  cannot  Ix.  ^aUn  as  com  11  ^^.^.t,,„„„, 

,,,  -isorption,  and  ^^^^^  ^^  ,  t:t'washing  w.ll  remove 
U  gelatine  ^ -^^  ^^^  ^  ^^^'^^^  ,i,„g  ,,„  remove  much  less  if 
:;;r"I  «:  ^..J  :i  '^^.  ^-ause  the  ^.rcentage  of  salts  on 

^^  ?Th  ::  v^^i  t  vm  mu  h  less  loss  of  salt  at  the  fourth  wash, 
^"on      .r  "r!:.^  there  is  not.  at  hist  sight,  any  d.f^rence 
^    .       n  the  nrocess  descrilx-d  by  Bayliss  in  washing  out  the 
ri/o'^olT^r^ino  a,u,  onUnary  w...ng  o„.  by  C,«-..„n. 
In  oach  case  the  rate  cl  loss  o(  salts  w.ll  be  sl.m. 

vLlmK  to  V.   Ik-mmclen.  the  factors  on  which  adsor  .- 
,„,  ■  cM.:nds  are  :    the  adsorhing  substance,  the  solvent,  the 

»  Above  atl,  o{  Gustav  Mann. 


I6 


STUDIES   IN    I'UNCTURK-FLUIDS 


sul)stanrc  to  bo  adsorbed,  tlu"  state  of  its  inolecules,  and  the 
tiMiiptratiirf. 

'I'ticsc  conditions,  liowtvcr.  aw  not  snttuicnt,  since  there 
must  1)  ■  a  liinr  I'lcnunt  to  consider. 

Fortunately,  the  sul)ject  beconie>  more  intelhgible  from 
H(')l>ers'  clear  and  distinct  diction.  This  author  |)oints  out  three 
properties  which  are  characteristic  ot  adsor])ti()n. 

1.  The  e(piilil)rinni  l)et\veen  the  ad>orl)ed  >ubstance  and  the 
nonadsorbi'd  substance  varies  according,'  to  whether  the  s'X'ond 
is  added  en  masse  or  by  instalments.  It  is  a  surface  tension 
[)licnonienon.  and  if  the  surface  l>e  altered  by  a  iHeliminary 
addition  a  further  addition  to  th  t  mu  lace  will  not  meet  with  the 
sauH-  condition:  as  did  the  hrst  |      iH"  i. 

2.  The  reaction  between  aii  ii!  and  >oKent  is  reversible 
oniv  for  a  shtjrt  time  after  its  ince])'ion. 

\.  The  e(iuilii)rium-constant  alters  wuh  tin  .'  ("  old-age  "). 

To  use  a  mathematical  expression,  we  may  say  that  if  an 
albuminous  fluid  adsorbs  chlorides  from  a  solution  of  chlorides, 
the  amount  a.lsorhed  will  depend  on  the  concentration  of  the 
tiuid  antl  of  the  solution.  Expressed  graphically,  a  curve  rei)re- 
senting  the  ratio  of  the  adsorbed  to  the  unadsorbed  substance 
{abscissa)  will  always  be  concave  towards  the  abscissa,  since  the 
power  of  adsor})tion  of  the  adsorbing  substance  is  greater  at  the 
beginning  than  it  is  at  a  later  stage  in  the  process.  When  this 
is  put  into  a  mathematical  formula,  we  have : 


'adsorl)ed  subst. 


-  k. 


unadsorbed  subst. 

where  k  is  called  the  adsorption  coef^cient,  and  /(  is  a  constant 
greater  than  i. 

This  fornmla,  however,  does  not  necessarily  hole!  good  only 
for  processes  of  adsorption,  i.e.  of  depression  of  the  surface 
tension  between  fluid  and  Cv)lloid.  by  the  dis.solved  substance. 
It  would  equally  well  expres.->  that  a  soliil  solution  is  formed 
in  wtii(  h  tile  chloride  is  divided  over  the  fluid  and  the  solid 
solvent.  There  may  be  a  question  of  electrical  charges  in  this 
asixnn  of  the  conditions. 

Without  pursuing  the  theoretical  side  of  the  (juestion  further 
ve  may  come  to  the  conclusionthat  if  the  effect  of  addmg  sodium 


TIIK   CHEMICAL  EXAMINATION   OF   PUNCTl'RE-FLUIDb      1/ 

fliloride  to  an  albuminous  solution  can  be  expressed  by  the 
formula  given  above  or  by  this  formula  : 

•^^'Cl  in  alb.=  ''-    V    ^Cl  in  water. 


wo    may    assume    that  adsorption  exists  between  these    two 

substances.  ■      „*. 

Several  tests  were  applied  in  order  to  endeavour  to  arrive  at 
a  conclusion  as  to  the  accuracy  ot  the  cM..ride  analyses  which 
have    been  made  in   puncture-fluids.     The  variations  m  con- 
ductivity shown  by  different  strengths  of  saline  solution  in  the 
presence  of  different  percentages  of  albumen  were  determined, 
and  in  another  series  of   tests,  different  solutions  of   egg-white 
and  sodium  chloride  were  made  up,  and  the  amount  of  NaCl 
estimated  in  each  volumetrically.     In  a  third  series  of  tests  a 
known  strength  of  natural  albuminous  fluid  was  treated  with  a 
known  quantity  of  NaCl,  and  different  dilutions  made   the  con- 
ductivity of  each  of  these  being  tested,  and  in  a  final  series  o 
exix^riments  a  known  strength  of  albuminous  solution  (human) 
was  treated  with  a  known  weight  of  albumen,  and  the  coagulum 
v.as  washed  with  distilled  water  on  successive  days  till  no  more 
chloride  could  be  detected  in  the  filtrate.     The  strength  of  NaCl 
and  the  conductivity  of  each   washing  was  determined.     The 
washing  was  carried  out  by  taking  up  the  coagulum  out  of  the 
filtrate,  transferring  to  a  small  flask,  and  adding  about  80  cc.  of 
water      The  contents  were  then  well  shaken  up  and  allowed  to 
stand'for  a  time.     The  mixture  was  then  filtered,  and  additional 
water  poured  on  to  the  precipitate  until  100  cc.  of  filtrate  was 

obtained.  .,,     ,     ^    .,  ., , 

Without  entering  all  the  results,  we  may  illustrate  the  method 

and  the  results  obtained  by  the  following  observations. 

I.  By  titration,  adopting  the  usual  method  of  de-albummisa- 

lion,  100  cc.  fluid,  containing— 


s : 

4 

4 

2 
2 
2 

2 


albumen  (egg)  + 

+ 


I  %  NaCl  yielded  0-85 


05 
025 
I 
-■>5 

01 


0-85  % 

NaCl 

on 

titration. 

0-45 

0*25 

I. 

092 

,. 

05 

M 

025 

.. 

01 

„ 

IS 


STrniKS    IN    I'UNTTrKK-KLUins 


2.  By  successive  washing, 


Kir.-t  filtrsf 
S(  cond 
Third 
Fourth      „ 

From  these  experiments 
albumen  is  low  there  is  no 


k26 


=  1800 
=    1035 

404 


an 


n 
20 


we  see  that  when  the  percentage  of 
adsorption  of  chlorides  by  proteid, 
while  with  higher  concentrations  of 
albumen,  however,  there  is  a  de- 
cided loss,  which  is  greater  the 
more  chlorides  there  are.  Putting 
the  results  of  the  last  table  in  the 
form  of  a  curve,  and  comparing  it 
with  that  from  an  ordinary  case 
of  adsorption  (tig.  i,  «),  it  is  at 
once  evident  that  there  is  a  dif- 
ference between  the  two.  From  our 
point  of  view,  then,  there  is  no  im- 
portant error  likely  to  arise  in  the 
ordinary  method  of  analysis,  pro- 
vided the  percentage  of  proteid  he  not 
large. 

Bugarsky  and  Liebermann  have 
settled  the  cjuestion  of  adsorption 
ol  XaCl  by  albumen  by  determining 
the     Ireezing-jioint     dejnession     of 

solution,  containing  varying  weights  of  albumen.     Thus  : 


a  roprt'Sfiits  tlu'  vaiyin;,' 
adxirption  occurring  in  dil- 
ftTfiit  conctntrations  of  Congo 
red  and  cellulose  (Bayliss), 
while  /;  shows  the  conditions 
which  obtain  in  the  case  ->( 
siriMii  alhiiniin  and  XaCl 
(.Author). 


Amount  of  Albumen 

Kreezinff  point 

100  cc.    1  NaCl 

DL-prtssion. 

20 

0 

0183= 

04 

Olio 

0-8 

OI()I 

1-6 

0194 

P 

0199 

6-4 

0-2(>3 

Freezing-point  Depression  if  no 
Adsurption, 


0183° 

0-183  +  0004  =  0-187 
0-183  +  0006  =  0-189 
0-183  +  0C09  =  0.192 
0183  +  0015  =  C198 
0183  +  0022  =  0205 


They  conclude  that  the  similarity  of  the  figures  in  the  second 


THE  CHEMICAL  EXAMINATION   OF   PUNCTURE-FLUIDS      I9 

and  third  columns  indicates  that  no  union  has  taken  place 
between  the  salt  and  the  albumen.  However,  the  fact  that  the 
observations  are  made  at  ordinary  temi^erature  and  at  about 
o""  C.  shows  that  such  an  experiment  does  not  decide  whether 
adsorption  might  not  occur  at  100''  C,  a  temperature  which  all 
the  puncture-fluids  have  to  attain  in  the  course  of  the  analysis 
recommended  in  this  w^ork. 


Scheme  fok  Analysis  of  Fcncture-fliids 

After  these  preliminary  observations  on  the  difficulties  with 
which  one  has  to  cojie,  we  may  proceed  to  formulate  the  method 
of  systematic  analysis  which  has  been  adopted  for  the  chemical 
examination  of  puncture-fluids. 

The  following  scheme  is  based  on  a  very  considerable  litera- 
ture, and  as  by  its  aid  more  than  200  puncture-fluids  of  all 
kinds  have  been  examined,  its  practical  advantages  have  hizn 
carefully  tested.  It  may,  however,  be  noted  that  there  is  not 
always  a  need  for  following  out  each  table  from  start  to  finish  ; 
a  judicious  selection  can  be  made  of  those  portions  of  the  scheme 
which  are  likely  to  give  information  in  the  particular  class  of  fluid 
under  examination.  Where  any  modification  of  the  methods 
has  been  found  convenient  a  mention  of  it  will  be  made  in  the 
appropriate  places. 

In  order  to  make  this  work  more  useful  to  those  who  wish  to 
apply  these  suggested  methods  for  purposes  of  diagnosis,  the 
confirmatory  tests,  especially  for  the  less  known  substances,  are 
entered  along  with  the  description  of  the  particular  substance. 
Inasmuch  as  there  are  constantly  being  devised  for  many  of  these 
bodies,  new  tests,  which  the  ordinary  reader  cannot  ascertain 
without  a  very  extensive  search  through  literature,  it  has  been 
thought  of  value  to  gather  together  these  innovations,  esjK-cially 
those  new  tests  which  have  been  found  of  use  in  the  Leeds 
General  Infirmary. 


20 


STUDIES   IN    I'UNCTrkK-KLriDS 


TABLE   A.     PRELIMI 

The  fluid  is  heated  in  the  presence  of  jnsl  oiniii^h  acetic  acid 
cess  in  a  water-bath  placed  on  a  sand-hath,  in  order  to  prevent 
to  boil,  a  few  drops  of  dilute  acetic  acid  are  added  until  a  coaguluni 
this  can  be  controlled  by  litmus). 

Coagulum. — This  consists  of  albumen,  globulins,  and  nucleo- 
meshes  (such  as  mucoids). J 

The  Filtrate  should  still  be  acid,  and  if  an  estimation  of 
by  adding  distilled  water  to  the  coagulum  in  the  filter-paper, 
the  remainder  is  tested  in  successive  jiortions,  thus  : 


Add  an  equal  part  of 
methxlateti  spirit. 


Add  liiisic  lead  ncelale. 


Precipitate 

IS  hftft'o- 
nlbiinios€, 
(c<.;i>r.  by  ; 

65^-.)   ; 

s.  p.  26 


Solution. 

Test  with  potass. 

ferrocyanide,  anil 

acetic  acid. 


PrecipiUM 

I 'rote  ids 

not 
required. 


Soiution. 

Remove  the  lead  by 

H..S. 


Precipi- 
tate not 
required. 


Solution 
Ptuttilbu- 

IllOSf. 

s.  p.  26 


Precipi- 
tate not 
required. 


Solution 


Kvap.  in  a 

drop  of  i)ure 

nitric  acid. 

Dissolve 

residue  in  a 

few  drops  of 

soda.  Warm 

in  a  platinum 

capsule.      If 

oily    drop 

forms  = 

leiiciii. 

3.  p.  27     ! 


Add  .Vninio- 
niacal  Silver 
.Nitrate :  Pre- 
cipitate = 
piirins.     Or 
evap.  to  dry- 
ness with 
HN03;add 
one  drop 
Ammonia. 
If  violet  forms 
=purins  or 
uric  add. 
(See  p.  31 
for  confirm- 
atory  tests ; 
also  footnote 
P-  -6.) 


*  Devoto 

t  'lo  detect  miclco-protcid  (Jolles).  Boil  the  original  fluid  witl'  excess 
After  24  ho  ;rs,  the  asbestos  filter  which  has  been  used,  and  the  precipitate, 
the  filtrate  with  acetic  acid,  redigest,  and  finally  purify  the  precipitate  by 
for  pliosphori\s  as  described  on  p.  40.  The  filtrate  from  ammonium  molyb- 
condenser.  The  fluid,  after  claritication.  polarises  light  to  the  right,  and 
with  jihenylhydrazin  (therefore  mucin). 

To  exclude  mucin  and  nucleo-albumen  from  nucleoproteid,  l)oil  the 
filter  while  hot.     Anipioniacal  silver    nitrate  precipit.Ttcs:    nucleoproteid 

X  Willanen. 

§  This  is  a  modification  of  Seliwanoff's  test  (p.  32),  which  I  believe  to  be 


Tin:   ClIKMICAL    KXAMINATION    OF-"    I'L'NCTUIiK-FF^L'IDS      21 
NARY    SEPARATION 

until  coagulation  results;  i  is  convenient  to  perform  this  pro- 

-xcessive  heating  in  the        lal  stages.     When  the  water  is  about 
ceases  to  appear  (only  some  half  dozen  drops  will  be  needed,  but 

proteid  t,  apart  from  substances  that  may  be  entangled  in  its 

chlorides  be  desired,  it  is  made  up  to  loo  cc.  (the  original  bulk) 
10  cc.  of  the  filtrate  are  then  set  aside  for  the  determination,  and 


^.tturatc  i\vi>  Ihirds 

with   Amnionium 

.Su!ptiat4  . 


Precipi- 
tate 

K  ntcro- 

iilbii- 

iiiose 

a 


Solution 

m.t   re- 
quired. 


Sat ur .tie  the  neutral 
i  sulutiun  with  Ani- 
:    monium  bulphate. 

Precipl-    Solution 
Mite        not  rt- 
Dciitiro-   quired. 


albu- 
mose 


Concentrate  another  portion        Neutralise  a 

of  the  filtrate  in  vacuo,  at  not     portion  ot'  the 

more    than    40°    C  ,   or    leave    filtrate      with 

:;  to  cci.centratc  spontaneously,     potash,      and 

;!  I'lace  the  fluid  in  a  porcelain    then    conccn- 

:   basin,  and  add   resorcin  till  a    trate    on    the 

fairly   strong   solution  results.      water-bath. 

Heat  the  basin  ovtr  a  liunsm  ,  If  a    precipi- 

llame.  after  the  manner  of  the  1  tate  forms  on 

Gunzberg   test   for    free    HCI,     adding     alco- 

and    if  a    red    colour    appear,     hoi.      suspect 

soluble  in  alcohol,  then  /evti/osr    the    presence 

is  present. i)    The   confirmatory     of         succinic 

;  tests  and  other  details  are   to    acid  (con- 

I  be  found  on  p.  32.  fi  r  m  a  t  o  r  y 

tests,  p.  194). 


of  water,  and  acidulate  with  acetic  acid.  The  precipitate  is  nucleoproteid. 
are  digested  in  an  Erlenmayer  flask  with  4  per  cent.  soda.  Ueprecipitate 
washing  with  alcohol  and  ether.  'I'he  dried  substance  is  incinerated  and  tested 
date  is  hydrolysed  for  2  hours  with  30  cc.  of  4-per-cent.  HCI,  with  a  reflux 
on  removing  lead  will  give  the  orcein  reaction,  as  well  as  give  a  glucosazone 

fluid  with  5  per  cent.  H,SO„  and  neutralise  with  baryta  while  hot,  and 

and  purins.     Mucin  and  nucico-albuiiicu  temaia  in  solution. 


convenient. 


22 


STl'DIKS   IN    I'UNCTrKK-KI.riDS 


TABLE    B.     SEPARATION   OF   GLOBULINS   AND    THEIR 

ASSOCIATES 

I.  Add  an  equal  part  of  thoroughly  saturated  pure  ammonium 

sulplialf,  and  leave  to  stand  ov-ernight  (or  longer). 


Solution. 

Contains     chielly    albumen    and 

secondary  albumoscs.* 
Nut  required. 


Ketldue. 

I>i;ilysr,  dry,  i'ud  vveipli. 

Contains  plobiilins,  nucleoalbumen,  piimary 

allnimosc,  peptone,  liistoncs,  and  lecithin 
(  I  I   Knse  some  of  the  residue  with  KOH  + 

KNO;,  and  te;,;  lor  phosphorus  (nucleo- 

albumen,  lecithin). 
(2)   iJissoKr   a    portion    in    water  and    add  ] 

act  til- arid  (lip  to  I      ).     After  prolongtd  j 

stardiuf:,  PrecipitaCb  -  sero  .ainmin.         ' 

2.  To  another  portion  add  ilouhle  the  hulk  of  saturated 
ammonium  sulphate  to  precipitate  the  eiiglohuhn.t 

♦  As  tlie  liltrate  contains  alliunieii.  it  may  be  boileil  as  in  Table  A 
and  the  'eiKlit  of  albumen  ul'imately  obtained.  The  ratio  between 
albiinien  and  pjlobulin  will  tlien  have  been  obtained  bv  the  one  process. 

t  .\  simjile  e.xj-.eriment  which  was  made  will  illustrate  the  importance 
of  delay  before  collectin'j  the  precipitates  obtained  by  salting  out  proteuls. 
toil  cc.  of  a  |ileural  lluiil  were  treati^d  with  .'■  ■■  cc.  ui  saturated  ammonium 
sulphate  itliiis  forming  a  '>'>-per-cent.  solution).  .\s  usual,  there  was  no 
effect  for  some  tin.e.  but  next  morniiiK  abundant  llocculi  had  separated. 
Tliey  weie,  however,  left  for  two  more  days,  and  then  filtered  otf.  The 
fluid,  which,  it  may  be  incidentally  mentioned,  was  turbid,  now  yitdded 
a  clear  liltrate,  anil  iiendiuK  further  study  of  this  liltrate  the  specimen  was 
left  in  a  i)liii;yiMl  ICrlenmeyer  Mask  for  ten  days,  at  the  end  of  which  time  it 
was  noticed  that  there  was  a  not  at  all  incon-.i(lerable  further  tlocculation. 
This  of  course  shows  that  ■-.iltiiif,'  out  may  take  several  clays  to  comiilete 
(there  ciniUl  be  no  coricentratiou  of  the  lluid  durinj;  this  time,  otherwise 
one  minht  argue  that  with  increasing  concentration  of  ammonium  sulphate 
a  ditteient  fraction  was  sejiarating) 

In  studvitig  the  ditterent  globulins,  bv  weighing,  and  ^o  on,  or  in  col- 
lecting globulin  in  order  to  estimate  associateil  lecithin,  one  conse<|ueii  ly 
neeiK  to  allow  a  coie-iderable  interval  to  elapse  before  regarding  the  salting 
out  as  complete. 

fa  the  other  hand,  in  a  note  by  Cecil  Bosamjuet  {Laiii\t.  1907)  he  states 
that  the  globulins  alter  on  standing,  so  that  the  relaticms  between  the  eu- 
and  jiseinlo-globulin  fractions  to  albumen  will  be  ditterent  in  the  same 
liuid  according  as  it  maybe  examined  immediately  or  after  a  time.  He  con- 
sidered that  an  enzymatic  change  occurred,  by  wliicli  albumen  mav  be  con- 
verted into  globulin.  The  view  is  |)robably  too  pessimistic,  because  if  one 
adds  the  values  given  for  "  ascitic  fluid  .\  "  one  tiniis  that  the  immediate 
estimation  gives  total  glolnilm  :  albumen  ---  j-^  :  n,  and  the  later  estima- 
tion still  gives  J  ?  :  im.  The  other  case  certainly  shows  a  change  from 
2-;  :  !•;  to  j-.><  :  i^  the  pseudo-globulin  having  decideillv  increased.  The 
duration  of  time  allowe<l  for  separation  of  the  precipitate  before  weighing 
might  easily  account  for  this,  in  the  same  wav  as  mentioneil  above  in  illus- 
trating the  need  for  delay  before  collecting  and  weighing  one's  precipitates. 


THI-:   CllKMICAL    EXAMINATION    OK    I'UNCTURE-FLUIDS      2} 


Before  proceeding  farther  it  will  be  advantageous  to  pause 
to  consider  the  substances  separated  by  Tables  A  and  B.  and 
discuss  those  properties  which  are  of  interest  in  connection  with 
the  study  of  puncture-fluids.  In  this  way  we  can  take  the  oppor- 
tunity to  indicate  in  which  fluids  the  various  substances  occur, 
and  their  significance. 

The  method  of  classification  adopted  consists  in  dealing  with 
the  proteids  first,  then  their  derivatives,  and  finally  the  sub- 
stances detected  in  the  latter  part  of  Table  A.  The  diaminoacids, 
which  demand  a  special  method  of  separation,  will  therefore 
come  ai)parently  out  of  turn,  but  owing  to  their  infrequency  in 
puncture-fluids,  and  to  the  complicated  procedure  necessary  to 
their  detection,  this  deflection  will  be  found  convenient,  as  the 
more  imjiortant  substances  will  be  taken  first. 

Albumen. — The  chief  interest  in  this  substance  as  regards 
its  presence  in  puncture-fluids  lies  in  the  evidence  which  it 
aftords  in  differential  diagnosis  of  exudates  from  transudates. 
This  side  of  the  subject  will  be  found  discussed  fully  in  Section 
I\'.  The  estimation  of  the  amount  of  albumen  is  also  of  great 
importance  in  the  detection  of  diseases  of  the  nervous  system  in 
the  case  of  cerebrospinal  fiuid,  and  this  will  be  iliscussed  later 
(Section  III.).  In  i)assing,  it  is  merely  sufficient  to  say  that 
there  are  four  types  of  effusion,  each  of  which  has  a  different 
albumen-content. 

a.  Due  to  disease  of  the  serous  membrane  (tubercle,  cancer, 
etc.).     Albumen  4-b  per  cent. 

b.  Due  to  venous  stasis  (general  or  local).  Albumen  1-3  per 
cent. 

c.  Extreme  hydraemia  (nephritis  ;  amyloid  disease).  Albumen 
less  than  05  per  cent. 

d.  Mixed  types.     Albumen  varies. 

The  amount  of  albumen  is  of  interest  in  other  kinds  of  fluid, 
as.  for  instance,  hydatid-cyst  fluid,  which  contains  very  little  as 
compared  with,  say,  pancreatic  cysts.  In  ovarian  cysts  there 
is  often  comparatively  little  coagulable  material. 

These  points  will  be  referred  to  under  the  appropriate  head- 
ings. 

Uvile  has  en^l'^ivonr,- !  to  -i'lnvv  tint  thers'  .irt'  two  varieti-As  of  serum- 
albumen,  a  "  fuserumalbumen,"  precipitabk-  by  weak  acid  after  saturation 
with  NaClor  magnesium  sulphate,  antl  coagulating  at  71  to  72'  C,  the  other 


24 


STUDIES   IN    rUNCTLKK-KLUIDS 


a  "  psrudo-struinall.uiiu-n."  wliitli  is  not  prtcipitablf  in  tlio  sanii-  mnnnrr. 
and   coamilatcs  at    S4     ('. 

Globulin.— The  scanty  attention  which  was  paid  to  tlie 
existence  of  this  proteid,  both  in  blood-serum  and  in  (pathological) 
urine,  in  former  years  is  gradually  giving  i)lace  to  a  much  more 
widesi)read  interest  than  it  has  enjoyed  in  the  hands  of  the  few 
who  concerned  themselves  with  pathological  chemistry.  It  is 
now  known  that  globulin  is  the  Ix-arer  of  many  important 
functions  ot  the  blood-serum.  of  which  the  relation  to  antitoxin 
is  i)erhai>s  the  most  conspicuous.  It  is  hrst  necessary  to  describe 
the  varieties  of  globulin  which  are  met  with,  because  it  is  imi)or- 
tant  to  distinguish  between  them  in  practice. 

Frtund  and  Joachim  iiave  classified  globulins  as  follows  : 


Name. 


I'rtcipiiant. 


.Solubility    Solubility  I  Solubility    iVecipi 


Water. 


"•''*"^^^'l  s^h. 


tatitin 
Limits. 


1.  Paraglobiilin 

or  Ovi- 
miiiiii  •  ... 

2.  Ktigliil'iilin 

3.  I'arap.st'tido- 

globiilin  or 
dysglobu- 
lin* 

4.  I'  s  e  u  (I  o  - 

globulin 

5.  Nucleoglo- 

biilin  (con-  j 
tains  I'.)...  i 


Cna^ula- 

ti.  n 
Temi-era- 

ture. 


Irclsat.AiiKSO,   Insoliibk 
II  Soluble 


sat.  Am^.ISOj 


Insoluble 
Soluble 


Soluble 


Insoluble 


Insoluble  ,  2'ii-yb 


Soluble 
Insoluble 


36-44 


70-77=C 
64  70X 


74-76'=C 
76^ 


These  authors  lay  stress  on  the  j^hysiological  importance  of 
these  varieties  of  globulin  bystating  that  pseudo-globuhn  contains 
the  antitoxin  for  tetanus,  paraglobulin  has  the  i)roperty  of 
l)recij)itating  egg-white,  cuglobulin  favours  the  precipitation  of 
myosin,  while  pseudo-globulin  inhibits  the  action  of  euglobulin.f 

The  same  authors  point  nut  that  a  globulin  may  be  (i)  soluble 
in  water  (pseudo-globulin),  (2)  soluble  in  06  per  cent.  NaCl,  but 
insoluble  in  water  (euglobulin),  (3)  insoluble  in  either  06  per  cent. 
NaCl  or  in  water,  but  soluble  in  0-25  i)er  cent.  NaaCOa.  This 
will  explain  the  characters  of  certain  kinds  of  peritoneal  exuda- 

♦  Of  Ohrmeyor  and  Pick. 

t  Tseudo-globuiin  thus  plaj-s  the  part  of  an  "  antiferment,"  as  it  were. 


Till.   (IIKMICAL   KXAMINATION    OF    I'f  NCTURK-FLUIKS      25 


tions,  since,  if  the  carbonates  be  present  in  excess,  the  third 
variety  of  globulin  will  be  in  solution,  while  if  there  are  deficient 
salts,or  if  the  chloride  concentration  of  the  fluid  be  less  than  that 
of  the  blood,  one  may  exi^ect  euglobulin  not  to  remain  in  solution, 
and  so  cause  a  turbid  })erit()neal  fluid.  V'e  shall  have  to  refer  to 
this  matter  again  wlien  we  come  to  de  d  with  opalescent  and 
milky  jx^ritoneal  fluids. 

As  regards  the  amount  of  globulin  which  is  present  in  a  fluid, 
it  cannot  be  said  that  this  shows  any  constant  relation  to  the 
nature  of  the  fluid,  though,  as  a  rule,  there  is  less  globulin  jiresent 
in  jileural  than  in  peritoneal  fluids.  The  abundance  of  globulin 
in  peritoneal  fluids  is  probably  an  explanation  of  tlie  strikingly 
more  frequently  occurring  opalescence  in  them  than  in  pleural 
fluids. 

The  varying  glolnilin-contcnt  of  fluids  is  shown  by  the  follow- 
ing table  of  some  of  the  analyses  from  cases  in  the  Leeds  General 
Infirmary. 

TABLE   I 

Gl.OBUI.IN-KlXTKNT   OF    I'lNC  TIKK-Fl-IIDS 


TMonolobular  Cirrhosis 
Tuberculous  Pciitonitis 
Peritoneal,  Cardiac 

Cardiac  and  Renal... 
lonolobular  Cirrhosis 
/■F.xudalion  (simple) 
Another  case 
Tuberculous  Exudate 
I  "  Idiopathic  " 


^'  Ca 
Ca 
Mc 


Pleural 


Cardiac  Failure 

w       >>  >• 

Ovarian        Simple  Unilocular  Cyst 


4-S«S  % 
o  s68  V 

0-25  % 
0-4  % 
0-06  % 
0-S8  % 
0-84  % 
1-8   % 

0-87 :; 

f36  % 

077  % 

o  04  ", 

184% 

2C79  % 


The  Substanxes  Detected  by  the  Filtrate  of  Table  A 

Albumoses  and  Peptones.— To  confirm  the  presence  of 

albumoses,  a  portion  of  the  filtrate  from  Table  A  may  be  (i) 

saturated  with  NaCl,  (2)  saturated  with  MgSO,,  (3)  dialysed.   The 

piotalbumose   will    pass    through,  while    hetero-albumose    will 

remain  behind. 

Protalbumose  made  alkaline  with  potash,  and  treated  with 
2  per  cent.  CuSOi  will  give  no  precipitate.  Hetcro-albumoso  is 
precipitated. 


26 


STLItll-S   IN    I'L'NCTI'UK-FLIIDS 


The  differences  l)et\veen  these  two  substances  may  l>e  tabu- 
lated tliiis  : 


lett. 


I'lotilbuiiiosc.        I  Secondary  Albumoie. 


NaCI  to  saturation  r  acetic  ai  id  satu- 
rated with  salt 
Biuret  (2  :  loo)  in  neutral  solution  ... 
Potaj^,   ferrocjanide  anil  aci  tic  acid 
Nitric  acid 


Precipitated 


No 

No 
No 


precipitated  in  salt-  only  precipitated  in 

free  solution  presence  of  salt 

Half  saturation  with  ammonium  sul-    cnmpUtc  pncipila-  No  precipitation 
phate                                                                  tion 

Tlie  investigations  which  liave  been  made  in  order  to  ascertain 
in  wliich  fluids  albumoses  and  iK'i)tones  were  or  were  not  present 
are  shown  in  Table  II.  It  will  be  at  once  noticed  that  peptone 
is  unitonnlv  absent  from  both  pleural  and  peritoneal  fluids, 
and  that  juirulent  fluids  contain  both  forms  of  albumose. 
This  is  as  mi^,'tit  be  expectetl,  for.  as  we  shall  see,  proteolytic 
ferments  are  a  conspicuous  component  of  the  polvnuclear 
leucocytes. 

Umber  states  that  ])rimary  albumose  is  always  present  in  a 
fresh  exudate,  and  that  deutero-albumose  is  often  met  with, 
while  true  peptone  is  absent.  It  will  be  seen  from  Table  II  that 
wiiile  protalbumose  is  absent  in  a  few  cases,  the  results  are  other- 
wise in  accordance  with  L'mber's  statement. 

TAHI.K  II 


Nature  of  Case. 

Hrol- 
albumose. 

Hetero- 
albumuse. 

Peptone. 

Pleural  ... 

bilateral  (single)  ... 

lubcrculous           

,, 
Cardiac  Failure 

idiopathic 

Chronic  Tubercular  .Nephritis    ... 
Empyema              ...         ...         .  . 

^         II 

Cardiac  (back-pies!-ure)  ... 
.Monolobular  Cirrhosis     ... 
I'eritoMcil  Cancer 
-Ad!.  Pericardi'.ini  ^haik-pri'Fsr.rc) 
(  hri  nic     Peritonitis    (non-tuber- 
culous)   ... 

Absent 

Present 
Absent 
Present 

,, 

Absent 
Present 

'• 
)i 

Trace      ' 
Absent 
Present 

Absent 

Present 

II 

Uniformly 
absent. 

Peritonea! - 

Absent 

11 

Trarc 

Uniformly 
absent. 

(  * 


Tin:   (  IIFMICAI.   EXAMINATION    OF   I'UNC TUkl-FI.UlDS      2/ 

The    Monaminoacids    (rIvcocoII,    leucin,    aspartic   acid, 

serin).  ,         .     ,  .  •     - 

Traces  of  these  substances  have  been  described  by  variou, 
authors  as  occurring  in  exudates.  es,>ecially  in  ,)eritoneal  thud.. 
Vmber  states  that  they  are  always  present,  but  from  the  e.v 
nerience  of  the  cases  in  the  Leeds  (ieneral  Infirmary  they  are  not 
found  at  all  frequently.  It  must  be  admitted,  however,  that 
possibly  too  small  a  quantity  of  fluid  was  utilised  for  their  detec 
tion  •  ^oo  cc.  or  more  might  furnish  better  pros,x<ct  of  detect mg 
them  but  hitherto  it  has  been  necessary  to  study  other  con- 
stituents more  particularly,  by  which  time  there  was  less  materia 
left  than  would  serve  to  reveal  the  presence  of  a  trace  of 
monaminoacid. 

The  method  of  separation  of  these  bodies  is  as  follows.  1  he 
filtrate  (iK.rtion  2.  Table  A)  is  carefully  neutralised  after  che 
treatment  with  H.S.  and  2  cc.  *  of  «K(1H  added.  It  is  now 
shaken  for  eight  hours  with  2-4  K>"-  «f  /i-naphthalen.-sulpho- 
chloride  (Merck)  by  the  aid  of  a  mechanical  shaker. 

\  separating  funnel  is  now  used  and  the  watery  fluid  is 
shaken  with  ether,  and  rendered  acid.  The  ether  takes  up  the 
fl-naphthalene-sulphaminoacids  out  of  this  acid  fluid,  especially 
if  a  little  powdered  ammonium  sulphate  lie  added  hrst.  The 
aminoacids  crystallise  out  and  can  be  recognised  from  their 
physical  properties  and  their  microscopic  appearance. 

This  method  is  employed  by  Erben  as  a  quantitative  method, 
but  since  he  admits  that  sometimes  only  577-  ^^nd  never  more 
than  80  per  cent.-varying  according  to  the  particular  aminoacul 
-is  recoverable,  it  can  hardly  be  recommended  for  quantitative 

purposes. 

Confirmatory  Tests. 

LECC.N^JJ5>CH.CH..CH.(NH..,).COOH. 

I.  Very  dilute  copper  sulphate  gives  a  blue  colour. 
2    Very  dilute  ferric  chloride  gives  a  red  colour. 
3'.  Mercuric  salts,   in   the    presence   of   soda,  give   a  white 
precipUate.  ^^^^  ^^^^  ^^^^  _^  ^^.^^^  ^^^^^^^  ^^^  ^^^^^^  ^^^^  ^^ 

excess),  and  boil  till  ammonia  ceases  to  come  ott.     Filter,  wa.h 
♦  More  if  necessary.     The  fluid  must  be  quite  alkaline. 


2S 


STUniKs   IN    ll'NCTLkK-II.riDS 


Willi  water,  aiKl  .vapor.itf  down  (iltrato  cm  a  water-l)atli.  If 
niT(-«s;ti  V.  (ilt.r  aKaiii,  and  ranfullv  .m  idify  with  acetic-  acid.  A 
crystalline  [.nripitatc  will  a|)|H'ar.  insoliil.le  in  ctli.'r.  Imt  s(.lnl>l.' 
in  alcohol  and  alkalies.  Meltimj-point,  _'o5  C.  It  crystallises 
nut  from  alcohol  in  lon^  ne.dles  of  isol.iitylhydantoic  acid. 
Detects  out  {,'ni.  lein  in. 

5-  Sc/unr's  /Vs/.  -Kvaporate  the  substance  in  a  drop  of  jmrc 
nitric  a(  id.  1'  --.,..  tli."  residu.'  in  a  few  droi)s  of  soda.  Warm 
in  a  i-latinuni  capsule.  If  l.-ucin  I..-  present,  an  oily  .hop  will 
ai)i)ear.  rolling  alM>ut  without  wetting  the  |>latinuni. 

(>.    I'he  acpieous  solution  is  htvorotatory  ,,„  —  -(>  1)5 '. 

7.  It  suhlimes  on  heatinj,',  and  givesoff  an  odour  of  ethylainine. 
Ci.Ytocoi.i.  CR,  (NH,.)  .  COOH. 

I.  A.M  K.nr  tmi,  .  ihr  «,,«!„  „,  ,|„.  ,ul.,taiK,.  to  1...  t.M.-.l  <,t  alcoholic 
M.h.t,o„  of  ,„cru  M.„t.  .;iyc,H:oll  p.crate  w,ll  separate  out  on  c,K,l>nK. 
-Miltllli;  point.    I.)<)     (  .  *" 

.-.   T\w  trystal,  Irom  ,■(  naplitiialeiu-siilplioclilori.U-  nult  at   15.,^ 
.?.  C  opp.r  Milpliatc  «ivrs  a  l)|iu-  colour.      (C  H  \o  )    („  +  n  O 

4.  On  .,M.lat,..ti  w,tl,  111).,  Klyoxyl.cacul  an.riormai.l.hv.lc- an-  iornu-.i 

5.  l>rrii  ililoridi- gives  a  (liip  rid  colour. 

AsPARTic  Acid  COOH  .  CH  (\H,)  .  CH,. .  COOH. 

1.  Copper  at.  late  giv.'s  a  l.lue  crystalline  precipitate. 

2.  Strongly  acid  solutions  are  (lextrorotatorv  fa,    =  ji--,  ) 
.1.   MeItin«-l.oint.   270  .  >   ^  "         -=3  7  )■ 

Th..  chief  ,ntc.r.st  of  this  particular  substance  li.s  in  its  association 
>s.th  flu-  all.un,,n  of  carcmon.a  tissue.  It  n.ay  const.tute  as  .nuch  as  5  to  10 
per  cent  of  the  al  ..onen  ..ol^culc  .n  tlu-se  cases,  and  should  therlre 
poss.My  be  nut  wuh  in  the  fluids  of  caicinoinatous  serositis.  In  its  detec- 
tion ,t  IS  n.cessary  to  remove  the  other  n.onaminoac.ds  first  \s,,artic 
acid  IS  an  essential  constituent  of  the  f-Iobulin  molecule. 

Hefore  passing  on  to  consider  the  i)urins  it  will  be  convenient 
to  describe  two  other  analytical  processes  which  are  of  use  in 
the  study  of  i)uncture-fluids,  though  not  available  for  routine 
work,  owing  to  the  time  which  is  involved,  and  the  absence  (so 
far)  of  any  definite  diagnostic  or  prognostic  deductions  to  be 
made  from  the  results. 

The  first  and  most  important  is  Hausmann's  method  of 
hydrolysis  of  pumturctiuids.  10  cc.  are  boiled  with  29  cc  of 
concentrated  Htl  for  five  hours  on  a  sand-bath,  using  a  reflux 
condenser.     Saturate    the  residue  with  calcined   magnesia  and 


TIIK   IIIKMICAI-   KXAMINATION   or   I'LXCTUKK-H  llltS      2() 

(li^til  ovt-r  tlu-  ammonia  into  decinormal  sulphuric  aciil.  It  is 
moil-  safe  to  placo  sufticii'nt  nia^m'sia  into  another  tlask  and 
add  the  result  of  hydrolysis  through  a  funnel.  In  this  way  no 
gas  will  Ix-  lost.  This  hrst  step  gives  the  amid-N.  As  soon  as 
distillation  is  complete  the  resitlue  is  dissolved  in  HCI,  brought 
down  to  a  small  bulk,  and  phosphotungstic  acid  addeil. 

After  24  hours  the  jnecipitate  is  washed  with  dilute  phos- 
l)hotungstic  acid,  acidulated  with  HCI  till  the  fluid  ceases  to  have 
a  yellowish  tinge. 

a.  Filtrate.  Make  up  to  500  cc.  and  Kjeldahlise  100  cc, 
to  get  the  tnonaminoacid-N . 

h.  Residue.  Dissolve  in  as  little  alkali  ;i.s  jKissible,  and  make 
up  to  a  definite  volume,  and  filter.  Kjeldahlist>,  to  get  tlm 
dtaminoacid-N. 

Scblbsing*  Method  of  Estimating  Ammonia.*  - 10  cc.  of  normal 
sulphuric  acid  is  plactd  into  a  sporulatniK  ilish  in  an  t'xsiccator.  anil  lo  cc. 
of  till-  fluid  to  bo  tcstctl  is  platt-d  in  tin-  ixsiccator.  50  cc.  of  milk  of  lii'u: 
is  added  to  the  fluid  and  tliu  covir  rapidly  placid  in  position  (vaseline  joint). 

\fter  three  days  the  sulphuric  acid  is  titrated  with       soda,  using  metlisl 

4 
orange  as  indicator  (turns  yellow).     Every  centimetre  of  the  sotla  which 
is  used  in  titrating  less  than  \i<)  signifies  -lo*)  gm.  ammonia. 

The  Purin  Bodies,  and  Urea.— The  purin  bodies  have  lieen 
the  subject  of  careful  study  in  many  quarters,  and  it  is  un- 
necessary to  enter  into  any  description  of  them  other  than  the 
facts  about  their  occurrence  in  puncture-fluids. 

As  regards  urea,  this  may  Iw  tested  for  in  the  filtrate  from 
Table  A  by  pouring  the  filtrate  into  excess  of  95  per  cent,  alcohol. 
After  several  hours,  the  extract  is  evaporated  over  a  low  flame, 
re-extracted  several  times,  and  the  final  extract  dried,  when 
cold  a  few  drops  of  nitrate  acid  are  added,  and  the  typical  crystals 
of  urea  nitrate  are  searched  for  24  hours  later,  t 

The  addition  of  hypobromite  to  a  portion  of  the  original 
fluid  will  also  reveal  the  presence  of  urea  owing  to  the  efferves- 
cence which  results.  As  a  rule,  however,  there  is  so  little 
gas  evolved  that  an  estimation  of  the  amount  of  urea  is  not 
jx)ssible. 

•  Uurig  gives  numerous  useful  hllle  prdCtiCal  details  in  BtJir.cm. 
Zeit.  iv. 

t  Salkowski. 


.^o 


STUDIES  IN    PUNCTUKE-FLUIOS 


■Il= 


TABLE   III 
Uhea-contknt  ok  I'l'nctl'hf.-Fluids 


Abfent  in. 


Kaiiit  Trace  in.  ;    Trace. 


Decided  Amount  in. 


riirombosis    of  Carcinomatous     I'leiiral  'Single  Pleural  Effusion. 


I'oital  Vein 
Cirrhosis     o  I 

Liver 
M  o  n  o  1  o  b  u  I  a  r 

Cirrhosis 
Toxic  Ntphritii 
Sarcoma       of 

Omentum 
Tuberculous 

Peritonitis 


Ascites  (2    Eliiision 

cases)  (3  cases)   Cardiac  Hack-pressure  (2  cases). 

Empyema. 
Hydronephrosis, 
Peritoneal  Fluids: 
Cardiac  Batk-pressure. 
Chronic  Peritonitis  (single). 

II  „        duet  J  Cirrhosis 

of  Liver. 
Peritoneal  Cancer. 


Syphilitic  Cirrhosis  of  Liver,  I  -42% 
(Poljakoff). 

From  this  table  it  will  be  seen  that  urea  is  much  more  fre- 
quently present  in  cases  of  pleural  than  in  cases  of  peritoneal 
effusion.  The  presence  of  urea  in  purulent  fluid  such  as  empyema 
may  perhaps  be  expected  from  the  fact  that  pus  contains  so  many 
extractives,  in  virtue  of  the  cellular  elements  in  it  (see  Section  III.). 

The  practical  deductions  which  can  be  made  from  the  pre- 
sence of  urea  are,  however,  scanty.  Its  occurrence  in  various 
l^leural  and  peritoneal  fluids  suggests  that  one  cannot  be  sure 
that  a  fluid  from  the  abdomen  is  from  a  hydronephrosis  just 
because  urea  is  jiresent  in  it.  Probably  we  need  to  know  the 
amount  of  urea  present,  in  order  to  be  able  to  say  that  there  is 
more  than  ordinary  autolysis  (rather  than  renal  secretion)  could 
account  for.  This  subject  is  again  referred  to  under  "  Renal 
Cysts  "  in  Section  III. 

The  purin  bodies  are  stated  by  Umber  to  occur  in  minimal 
traces  in  exudates. 

They  are  best  separated  by  precipitating  the  phosphates 
with  ammoniacal  Ludwig's  magnesia  mixture,  and  then  adding 
05  per  cent,  silver  nitrate  in  50  })er  cent,  ammonia  to  the  filtrate. 
The  precipitate  is  placed  on  an  ash-free  filter-paper,  and  washed 
till  the  filtrate  is  no  more  alkaline.  The  residue  is  boiled  in  a 
Kjeldahl  flask  with  water  and  some  magnesia,  and  is  then 
Kjeldahlised.  In  this  way  the  nitrogen  of  the  purins  is  estimated. 
The  uric  acid-nitrogen  is  also  determined  in  another  ixjrtion  of 


\i 


THE   CHEMICAL   EXAMINATION    OF    I'UNCTURE-FLUIDS      3 1 

fluid,  and  the  ditference  between  the  two  values  gives  the  nitrogen 
of  the  purin  bases. 

The  time  involved  in  separating  out  the  individual  punns  is 
not  profitably  spent  in  connection  with  puncture-fluids.* 

ConfirmatorvTests.^i.  Burians  Test.-Make  the  solution  alkaline  with 
so<la,  and  add  a  solution  of  diazobenzcnesulphonic  acid.  An  intense  r«l 
colour  results.     (Cf.  Test  6  for  tyrosin,  p.  35.)  ,  .     , 

2  Weidels  Test.— A  small  portion  is  evaporated  in  a  porcelain  basin 
with' freshly  prepared  chlorine  water,  and  when  dry  the  basin  is  invcrte<l 
over  an  open  ammonia  bottle.  If  purins  are  present,  a  rt-.l  or  purplish  rvd 
colour  will  appear,  turning  violet  when  warmed  with  a  little  potash.  In 
place  of  chlorine  water,  hydrochloric  acid  and  a  small  quantity  of  potassium 

chlorate  may  be  added. 

Reaction:   xanthin  =  alloxan +  NH,=  murexid  reaction. 

^    Nitric  ^cid  Test.— If  the  fluid  be  heated  with  strong  nitric  acid  and 

evaporated  to  dryness,  the  residue  treated  with  soda  gives  a  violet  or  purple 

red  (turning  indigo-blue  when  dry). 

TABLE  IV 
PuKiNs  IN  Puncture-Fluids 


Present  in 


Absent  in 


I 


Chronic   Pleural 
tuberculous) 


Effusion    (non-     pif,ufai 


Simple  Chronic  Peritonitis 


rn, 

-  Tr 


Tuberculous 
^    .      -.  Transudatory 
effusion  ^  Empyema 

i'Throinbosis  of  Portal  Vein 

.  I  rirrhnsis  of  l.ivpr 
Peritoneal  (  ^a^coma  of  Omenlum 
tluiu         I  Peritoneal  Carcinomatosis 
I  Cardiac  Failure. 


From  this  it  will  be  seen  that  purin  bodies  are  really  only 
rarely  met  with,  at  any  rate  in  appreciable  amount.  If  they 
only  occur  in  infinitesimal  quantities  it  is  certain  that  the  amount 
of  fluid  available  in  the  cases  detailed  was  not  great  enough  to 
allow  of  the  detection  of  these  bodies. 

The  Sugars.— The  presence  of  leviilose  was  discovered  by 
Pickardt,  who  found  it  present  in  very  many  ascitic  and  peritoneal 
fluids,  as  will  be  seen  in  the  table  on  page  150.  The  method 
advocated  for  its  detection  has  nevertheless  failed  to  show  its 
presence  in  several  of  the  fluids  examined  by  me. 

The  method  to  be  adopted,  where  an  estimation  of  the  amount 

*  The  same  applies  to  Krugcr  and  Schittenhelm's  method,  though  in 
the  case  of  fa;ces  its  value  is  different. 


32  STl'DIKS   IN    I'UNCTUKE-FLUIDS 

of  reducing  body  is  desired,  is  as  follows :  After  concentrating  the 
filtrate  from  albumen,  the  fluid  is  boiled  five  minutes  with  half 
as  much  yS-jjer-cent.  alcohol  as  there  was  of  original  fluid.  Cool 
and  filter*  The  filtrate  (or  mixture  of  alcoholic  filtrates)  is 
decolorised  with  animal  charcoal.  The  amount  of  reducing  sub- 
stance in  one  portion  may  be  estimated,  and  the  amount  of 
methylphenylhydrazin  necessary  can  be  calculated  from  this, 
adding  three  molecules  of  hydrazin  compound  toeach  molecule  of 
levulose  found.  This  substance  is  added  to  the  alcoholic  solution 
and  allowed  to  stand  some  hours,  and  the  filtrate  is  kept  at 
40°  for  twenty-four  hours  to  allow  the  ozazone  to  crystallise  out  f 
fructose  methylphenylglucosazone 

C.H,OM-(CHOH),  -C-CH:  N  .  N(CH,)CF?, 
II 
N  N.  CH,  C„Hj 

Confirmatory  Tests. — i.  When  boile<l  with  rcsorcin  and  HCl,  a  red 
colour  soluble  in  alcohol  results  (Seliwanoff' s  reaction.)  ♦ 

2.  It  is  hrvorotatory.     (oi,.= -113-96'). 

3.  In  presence  of  ethereal  salt  of  HBr  a  deep  purple  colour  appears 
(brommethylfurfurol). 

4.  With  phenylhydrazine  it  gives  an  osazone  exactly  like  glucosazone 
or  mannosazonc  or  chitosamindsazone. 

5.  It  ferments. 

6.  The  proof  is  the  finding  of  the  methylosazone.  which  melts  at  158- 
160°  C.  If  the  crystals  have  a  reddish  colour  (being  impure)  they  mav  melt 
at  153-.  Optically,  0-2  gm.  in  a  mixture  of  4  cc.  pyridin  and  6  cc.  absolute 
alcohol  will  rotate  1°  40'. 


11 


Pentoses. — These  are  rarely  met  with. 

Confirmatory  Tests.— Vac  the  filtrate  from  Table  .\  after  concentration. 

I-  To  05  gm.  orcin  tlissolved  in  10  cc.  of  25-pcr-cent.  HCl  add  i  cc. 
of  lo-per-cent.  ferric  chloride,  and  add  the  fluid  to  be  tested.  Shake 
thoroughly  while  warming.    .S  green  colour  will  appear  if  pentose  be  present. 

•  The  precipitate  consists  of  salts  and  a  little  fructose  sometimes.  If 
fructose  does  come  down  the  alcohol  extraction  must  be  repeated. 

t  If  only  an  oil  forms  (sorbose),  it  is  separated  and  washed  with  dis- 
tilled water  by  decantation,  and  then  dried  completely  over  H  SO,  in  vacuo. 
The  resulting  resin  is  dissolved  in  absolute  alcohol,  filtered,  and  frozen 
crystals  will  I)c  founil  to  separate  at  once  and  may  be  purified  by  re- 
crystallisation  and  final  extraction  with  pyridin. 

I  This  test  is  also  given  by  all  polysaccharids  which  will  yield  fructose 
on  hydrolysis  ;  it  means  that  a  ketose  of  the  6-CHO-series  is  present,  e.g. 
togatose.  galactose,  pseudo-tructosc,  o-oxyglycuroic  acid,  cellulose  (filter- 
paper  !) 


THE  CHEMIC.XL  EX.\MINATION   OF   PUNCTURE-FLUIDS      3^ 

2.  It  does  not  ferment. 

3.  Spectrum  analysis.  Heat  with  fuming  HCl  and  phloro^lucin  = 
cherry-reil  colour,  giving  a  dark  band  between  D  and  E. 

4.  To  the  tluid  add  1  part  /)-bromphenylhydrazin,  3  J  parts  50-per-cent. 
acetic  acid,  and  12  parts  water  =  bromphenylhydrazone. 

5.  Heat  with  1  vol.  xydidin,  i  vol.  glacial  acetic  acid  and  \  vol.  alcohol. 
.\n  intense  red  of  furoxylidin  is  produced. 

The  Diaminoacids. — Lysin  and  Arginin. — Umber  has  only 
found  faint  traces  of  diaminoacids  in  exudates,  hut  probably  they 
are  only  occasionally  present  in  puncture-fluids.  Their  separa- 
tion is,  however, a  matter  of  some  imjwrtance,  because  with  this  is 
bound  up  the  question  of  the  residual  nitrogen,  to  which  interest 
is  attached  in  reference  to  pathological  metabolism. 

TABLE   C.     SEPARATION    OF   DIAMINOACIDS 

Add  phosphotungstic  acid  till  the  fluid  is  only  just  alkaline. 
An  e.\cess  of  acid  must  be  avoided  in  order  to  prevent  albumen, 
albumoses,  nucleoalbumens,  etc.,  from  coming  down. 


I  he  precipitate*  is  made  up  of  only  diaminoacids,  uric  acid,  purins,  and  phosphates, 
bhake  with  boilinj;  baryta  water. 


Precipitate 

=  phos- 
phates. 


The  Solution  is  divided  into  two  parts : 

A 

Neutralise  with  H,S04. 

B 

Pass  in  CO.(  and  boil. 

PreclpiUU 

=  BaSO^. 

■olution. 

PreclpiUU 

=  baCo,. 

■olution. 

Add 

Neutralise 
with  HCl 
and  add 
alcohol. 

Precipitate 
=  lys'H 
chloride. 

Add  AgNO,  and 

then  baryta  water. 

Pass  in  COj. 

AgNOj  and 
filter. 

Concen- 
trate the 

' 

Precipi-  Solution 

tate  —     concen- 

BaCO,.  trated  by 

boiling. 

'  Arginin 
1      will 
I  crysUl- 
;  lise  out. 

filtrate 
and  add 
alcohol. 

Lysatinin 

will 
crystallise 

out. 

Alternative  Method. — Acidify  the  solution  with  dilute  HCl, 
dry  on  a  water-bath,  dissolve  the  residue  in  alcohol,  and  add 

*  That  portion  of  the  nitrogen  of  the  precipitate  which  remains  after 
subtracting  the  nitrogen  of  the  ammonia  and  the  nitrogen  of  the  purins  is 
called  residual  nitrogen,  and  it  is  determined  by  the  use  of  Kjcldahl's  method. 


34 


STUDIES   IN    rUNCTURE-FLUIDS 


!  ;. 


concentrated  alcoholic  picrolonic  acid  till  no  more  precipitate 
falls  (cholin.  neurin,  lysin).  The  crystals  may  be  studied  and 
identified  (melting-point,  e.g.). 

Lysin  gives  brilliant  yellowish  orange  prisms  with  platinum 
tetrachloride  (a  platinum  double-salt). 

The  Residual  Nitrogen.— Attention  to  the  amount  of 
residual  nitrogen,  not  only  in  blood  but  in  various  effusions,  was 
especially  drawn  by  Neuberg  and  Strauss.  After  removal  of 
albumen,  the  amount  of  nitrogen  which  is  precipitable  by  phos- 
jihotungstic  aciil,  as  also  the  amount  which  is  not  precipit- 
able by  that  reagent,  are  determined.  These  authors  make 
the  (.lefinite  assertion  that  by  the  use  of  a-naphthylisocyanate  * 
(CO.  X.  C|„  Hr)  there  is  no  risk  of  finding  an  aminoacid  which 
was  preformed  in  the  albumen  molecule.  The  cases  may  be 
divided  into  the  following  three  groups  : 

1.  Where  the  nitrogen  of  the  amino  compound  is  less  than 
o'5  per  cent.  This  group  includes  cases  of  subcutaneous  (cdema 
associated  with  tubal  renal  disease,  as  well  as  similar  cases  asso- 
ciated with  cardiac  incompetence. 

2.  Where  the  amino-nitrogen  lies  lietwecn  05  and  i  per  cent. 
— as  occurs  in  pleural  exudates  (056  per  cent.),  cardiac  and 
renal  cases  (0-65,  oSi  per  ctiii.),  and  in  a  case  of  Banti's  disease 
(o()2  per  cent.). 

3.  Where  the  amino-nitrogen  lies  above  i  per  cent.  This  has 
been  found  in  a  case  of  ascites  associated  with  cirrhosis  of  the  liver. 

Glycocoll  is  never  found  in  subcutaneous  (edema  fluid,  or  in 
cases  of  cardiac  back-pressure. 

The  Oxyaminoacids. — The  only  member  of  this  group 
which  calls  for  attention  is  Tyrosin,  which  is  rat  rarely  met  with 
in  association  with  leucin.  Its  presence  has  been  recorded  in 
the  peritoneal  fluids  in  cases  of  alcoholic  cirrhosis  of  the  liver. 

•  Aniinoacids  in  alkaline  solution  react  rapidly  with  a-naplithylisocyan- 
atc.  The  mixture  is  shaken  two  to  three  minutes  anil  then  left  to  stand  for  a 
half  to  three  quarters  of  an  hour.  The  dinaphthylurea  is  filtered  off.  and 
the  filtrite  acidified  with  HCl.  The  corresponding  naphthvlantoic  acids 
fR.CH.  (NH  .  CO.  NH  .  CJl,  C  H)-C00H:  which  are  insoluble,  are  formed. 
The  precipitate  is  dissolved  in  dilute  ammonia,  then  in  a  little  alcohol. 
Baryta  water  prwlucesa  precipitate  of  o-naphthylisocyanate  of  glycocoll — 
needle-like  crystals  [(C,„H;  .  NH.  CO.  NH,  CH,.  COO),— Ba.]  melting  at 
lyl°  (mean).  The  leucin  derivative  melts  at  lOj^",  the  lyrosiii  derivative 
at  205-2y()°  C.  The  mixture  of  the  isocyanatcs  can  be  subjected  to 
fractional  distillation. 


f  * 


THE  CHEMICAL  EXAMINATION  OF   PUNCTURE-FLUIDS     3$ 


This  substance  is  generally  identified  with  leucin.  The 
following  tests  may  be  used  : 

Confirmatory  Tests.  —  i.  Millon's  reagent  gives  the  same  reaction  as 
when  used  for  proteiils,  the  reaction  in  their  case  being  due  to  the 
pre-ience  of  tyrosin  in  the  molecule.* 

2.  Quinone  Test. — .\dd  dry  quinone  to  the  solution.  A  deep  ruby  colour 
forms,  turning  to  violet  red  on  adding  sodium  carbonate. 

3.  Piria's  Test. — .\dd  sodic  sulphate,  pour  this  into  water  and  neutralise 
with  barium  carbonate.  Filter,  add  a  drop  of  neutral  ferric  chloride, 
when  a  beautiful  violet  colour  appears. 

4.  Aldehyde  Test. —.\cidify  with  H, SO,  (2  cc.)  and  add  aldehyde  (four  drops 
of  30-per-cent.  alcoholic  solution).  .\  carmine  colour  forms  (condensation 
product),  giving  an  absorption  band  covering  green  and  nearly  all  the  yellow. 

5.  Formol  in  the  presence  of  H  SO,  gives  a  brownish  yellow  colour 
01.  heating,  and  on  boiling  with  twice  its  bulk  of  glacial  acetic  acid,  it  turns 
green  (Denigcs'  test). 

(Morner's  Test. — Solid  substance  added  to  i  vol.  formalin,  45  vols, 
water,  and  55  vols,  concentrated  sulphuric  acid,  gives  a  permanent  green 
colour  on  boiling.) 

6.  Diazobenzenesulphonic  acid,  in  the  presence  of  potash,  gives  a  red 
colour.     (Th>-  only  fallacy  to  this  test  is  the  presence  of  histidin.) 

GLYCOPROTEIDS 

The  diagnosis  of  a  puncture-fluid  from  an  ovarian  cyst  is 
occasionally  necessary,  so  that  it  is  important  to  discuss  the 
properties  of  those  substances  which  lend  a  distinctive  character 
to  the  contents  of  ovarian  cysts  from  a  chemical  point  of  view. 

The  most  important  of  these  glycoproteids  is  pseudo-mucin, 
which  was  first  carefully  studied  under  the  name  of  metalbumen 
by  Hammarsten  in  1882.  It  is  so  called  because  it  is  not  precipi- 
tated by  acetic  acid,  and  yet  has  a  mucinous  consistence.  The 
presence  of  allied  substances  in  the  peritoneal  fluid  and  in  the 
synovial  fluid  renders  the  subject  not  only  one  of  academic 
interest,  but  also  of  interest  to  the  diagnostician. 

Glycoproteids  are  substances  which  contain  a  carbohydrate 
radicle  (mostly  in  the  form  of  glucosamin)  attached  to  the  proteid 
molecule,  and  it  is  the  glucosamin  which  is  responsible  for  the 
similarity  of  the  reactions  between  the  various  substances  above 
named.  | 

•  The  use  of  this  reagent  for  distingui-shing  between  tubercular  and 
non-tubercular  exudates  is  referred  to  in  Section  IV. 

t  Tke  glycoproteids  arc  fully  described  in  Mann's  "  Chemistry  of  the 
Proteids,"  but  many  pomts  of  mterest  m  the  present  connection  lind 
only  scanty  notice  there,  so  that  one  feels  justified  in  entering  thus 
fully  into  it. 


3^  STUDIES   IN    I'LNCTURE-FLUIDS 

(llucosamin  is  dextroso  with  the  H  atoms  of  one  of  the  two 
CH:;()H  {,'ioups  rephued  by  an  amino  group  (XH^),  so  that  it 
forms,  as  K.  Fisher  pointetl  out,  a  link  between  carlH)hydrate  and 
jMoteid.     The  reactions  of  this  sul)stance  are  : 

1.  The  MoHscli  reaction  is  positive  (alcohohc  u-naphthol  fol- 
lowed by  strong  sulphuric  acid,  gives  a  violet  colour  which  is 
turned  yellow  by  alcohol,  ether,  or  potash). 

2.  It  does  not  ferment  with  j-east. 
J.   It  gives  Trommer's  test. 

4.  It  gives  a  glucosazon  melting  at  202"  C. 

5.  It  gives  Ehrlich's  glucosainin  test  after  adding  an  alkali 
such  as  baryta,  and  then  warming.  (This  test  consists  in  a  red 
colour  obtained  on  adding  a  2-  to  5-per-cent.  solution  of  /)-dime- 
thylaminobenzaldehyde  dissolved  in  normal  hydrochloric  acid  * 
till  acid.) 


TABLE  D.  SEPARATION  OF  GLYCOPROTEIDS 

I'o  the  tluid  add  three  times  its  bulk  of  absolute  alcohol.     Shake  occasionally. 


I'ortioii  I 
Allow  to  stand  ^4  hours. 


I'lirtion  2 
AMdw  to  stand  j  to  3  months, 
then  evaporate  the  alcohol  at    i 
40'  C. 


Portion  3 
Kilter  at  once. 


Precipitate. 

Shake  with 

slightly  alkaline 

distilled  water. 

Filter. 


Solu- 
tion. 

not  re- 
quired 


Precipitate. 

Shake   with 

slightly  alkaline 

distilled  water. 

Filler. 


Solu- 
tion, 
not  re- 
quired 


Resi- 
due. 
not  re- 
quired 


Fil-     I 
trate. 

Test 
for      ' 
Pseudo- 1 
mucin 


1 

Resi- 

Fil- 

due. 

trate. 

not  re- 

Test for 

quired 

Cholin, 

Lecithin, 

Mucin 

;  i 


Resi-         Fil- 
due.       trate. 
not  re-     Add  to 
quired    solution, 
or  lest 
separate- 
ly for 
albu- 
moses 

Serosamucin  (Umber). — This  has  been  found  in  peritoneal 
fluids   due   to   inliammatory  processes  or    to   new-growth    dis- 

•  Normal  HCl  is  made  by  adding  5  cc.  water  to  i  cc.  pure  hydrochloric 
r.cid. 


Precipitate. 

Shake  with 

distilled  water. 

Filter. 


Solu- 
tion. 
Test 
for 
Albu- 
moses, 
Mucin. 


THK   CIIEMICAI.   EXAMINATION   OK   rUNCTURE-FLLIDS      37 


stinination.  The  L,uhstance  will  come  out  of  solution  if  to  the 
(U'-alhuniinised  fluid  a  small  quantity  of  very  dilute  acetic  acid 
i>  added.     The  precipitate  will  have  the  following  reactions  and 

propertic-; : 

1.  I.t't  ono  drop  of  solution  drop  from  a  glass  rod  into  a  loo-cc.  measure 
ol  distilled  water  to  which  a  couple  of  drops  of  glacial  acetic  acid  have  been 
adiled.  A  cloud  will  appear  if  serosamucin  be  present.  The  precipitate- 
ly soluble  in  motlerate  excess  of  acid,  and  is  reprecipitated  by  further 
dilution,  while  it  may  be  reilissolved  by  rendering  the  fluid  neutral  or 
-lf.;htly  alkaline  (Rivalta's  test). 

2.  It  contains  a  minimal  amount  of  reducing  substance. 

V  It  is  precipitated  by  alkaloidal  reagents,  such  as  potassium  ferro- 
cvanide.  nitric  acid,  copper  sulphate,  ferric  chloride,  lead  acetate. 

4.  It  is  precipitated  by  an  equal  volume  of  saturated  ammonium 
sulphate. 

5.  It  gives  the  biuret  reaction. 
(k   It  gives  Millon's  reaction. 

7.  It  gives  the  xanthoproteic  reaction. 

8.  It  gives  a  strong  furfurol  reaction  (Molisch  reaction). 

9.  It  gives  .\damkiewitz'  reaction. 

10.  It  gives  Liebermann's  reaction. 

11.  It  is  not  coagulated  when  boiled  in  neutral  solution. 

12.  It  is  not  separated  by  dialysis. 

13.  It  forms  a  precipitate  when  digested  with  pepsin. 

14.  It  gives  an  absorption  band  in  orange,  and  slight  darkening  to  the 
kit  of  red  when  treated  with  orcein  hydrochloric  acid,  and  extracted  with 
amyl  alcohol,  possibly  indicating  pentoses  or  glycuronic  acid. 

The  percentage  of  nitrogen  and  sulphur  has  been  remarked  on  by 
Umber  as  showing  the  body  to  belong  to  the  mucins. 

The  question  as  to  the  nature  of  this  substance  is  still  unsettled. 
Whereas  Umber  considered  it  to  be  a  mucin,  though  not  a  true 
mucin,  because  it  contains  too  much  nitrogen,  Langstein  objected 
to  this  view,  on  the  ground  that  a  reducing  substance  can  be 
obtained  from  all  proteids.  Stiihelin  considers  the  body  to  be 
related  to  globulin,  since  it  possesses  similar  solubilities,  and  is 
precipitated  by  half  saturation  with  magnesium  sulphate,  and  is 
not  separated  out  by  dialysis. 

A  similar  discussion  has  been  raised  about  the  mucin  of  the 
urine,  which  was  once  regarded  as  a  mucin,  then  as  a  body  re- 
lated to  Bence  Jones'  proteid,  then  as  a  globulin,  then  as  a  nucleo- 
albumen,  then  as  nucleohiston.  Stahelin  believes  the  urinary 
substance  to  be  identical  with  that  of  the  peritoneum,  and  with 
that  found  in  blister  fluid.  Rivalta  and  Primavara,  more  recently, 
regard  it  as  a  mixture  of  euglobulin  and  pseudo-globulin.    That 


38 


STUDIES  IN   PL'NCTURE-KLUIDS 


it  is  not  a  histone  is  established  by  the  fact  of  its  yielding  no 
histone  even  after  treatment  with  08  per  cent.  HCl  for  days. 
Pseudo-mucin. — The  reactions  of  this  substance  are  : 

1.  On  boiling  with  a  small  (juantity  of  dilute  sulphuric  acid  the  fluid 
ac(iuires  the  power  of  reducing  FihlinK. 

2.  The  opalescent  filtrate  tjives  a  turbidity  but  no  precipitate  on  boiling. 

3.  Acetic  acid  gives  no  precipitate. 

4.  Acetic  acid  and  potassium  ferrocyanide  rentier  the  fluid  viscid  and 
impart  a  yellow  coloration  to  it. 

5.  Millon's  reagmt  yives  a  bluish  red  colour  on  boiling. 

(>.  Glyoxylic  acid  ♦  followed  by  sulphuric  acid  gives  a  violet  coloration. 

I'seudo-mucin  has  been  fully  studied  by  Otori  in  order  to  determine 
what  decomposition  pro<lucts  could  lie  obtained  from  it.  The  substance 
was  boiled  with  hydrochloric  acid  and  tin  chloride,  and  the  filtrate  ex- 
tracte<l  with  .  ther,  the  fatty  acids  being  thus  removed  and  estimated 
ultimately  as  sdver  salts.  Silver  sulphate  was  used  to  extract  histidin, 
arginin.  and  lysin,  and  picrolonic  acid  was  used  to  obtain  arginin  and 
guanidin. 

The  following  result  of  analysis  shows  the  various  derivatives  which 
have  been  found  in  pseudo-mucin,  anil  which  are  therefore  presumed  to 
occur  preformed  in  the  pseudo-mucin  molecule  : 


luo  parts  pMudo-mticin  yield. 


On  sulittinE  up  by 
(grammes). 


On  splitting  up  by 
HCl  +  SnCl.i 
itirammes). 


Ammonia          



07517 

3239 

Guanidin 

00393 

0-0250 

Arginin 

... 

0-2V75 

07773 

Lysin 

26389 

2-582 

Tyrosin             

roSg 

0-4422 

Leucin 

4677 

4431 

GlycocoU 

0-146 

Glutaminic  acid 

Aspa rag ic  acid 

— 

0-5945 
Trace 

Oxalic  acid 

01275 

Levulir.ic  acid 

1-971 

__ 

Valerianic  acid  (?) 

0765 

Formic  acid 

Present 

Present 

Acetic  acid,  Propionic  acid,  reckoned 

as  acetic  acid 

.■ 

Not  estimated 

0-i6l 

Reducing  body,  reckoned  as 

glucof . 

07333 

0-429 

Insoluble  humin  substances  . 

6056 

7005 

A  means  of  identification  of  pseudo-mucin  which  is  absolutely  reliable 
was  worked  out  in  1900  by  Zangerlc,  who  prepared  a  glucosamin  compound 
after  benzoylising  the  substance.     The  method  is  not  of  clinical  value,  as  it 


*  Glyoxylic  acid  is  prepared  by  putting  sodium  amalgam  into  saturated 
aqueous  oxalic  acid.     Filter. 


•I 


THE  CHEMICAL  EXAMINATION   OF   PUNCTURE-FLUIDS     39 

is  far  too  teilious.  but  it  is  important  when  there  is  a  need  to  be  certain  that 
I  Eiven  mucinous  substance  is  or  is  not  ulcnt.cal  wth  some  other  mucmous 
substance  already  known.     Briefly,  the  metho<l  consists  in  s..paratmg  out 
the  substance  by  the  a«l  of  alcohol,  after  which  ,t  is  treat«l  w.th  hydro- 
chloric acul.  and  fre«l  of  albumoses.  and  the  fluid  U-nzoylated  by  the  use 
of  benzoyl  chloride  and  so<la  t  ill  the  filtrate  ceases  to  reduce  Fehlmg       The 
benzoyl  compound  isdr.e.l  an.l  dissolved  in  hot  alcohol,  from  which,  after 
standine    crystals   of    tetrabenzoylRlucosamtne   separate,   mi.xed    w.th    a 
certain  amount  of  pentabenzoylglucosamine.     The  crystahne  compouml 
,s  dissolvwl  in  alcohol,  precipitated  (cold)  and  redissolvwl  (heat),  and  then 
„our«l  into  excess  of   <list,lle<l  water  to  get  rid  of   inorgan.c  salts      The 
,urifi«l  substance  is  heated  to  ioo»  C.  for  nearly  two  days  m  seaUxl  tubes 
Ihich  are  three  quarters  full  of  strong  HCl.     Crystals  wdl  then  be  found 
m  the  tube,  and  can  be  purified  by  the  use  of  ether,  and  dried  m  vacuo  over 
l.me  to  get  rid  of  water  and  HCl.     A  brown  syrup  is  ultimately  obta.ne.  , 
which  deposits  glittering  rhomboidal  crystals  insoluble  in  alcohol,  so lub  e 
in  water  (a  fact  made  use  of  for   purifying  them).     The  following  table 
shows  that  the  crystals  are  practically  identical  with  other  glucosam.ns. 
and  indeed,  one  may  say  that  the  mucinous  secretions  of  goblet  cells  in  any 
nart  of  the  body,  be  it  in  the  air  pas.sages.or  in  the  intestine,  or  m  cysts, 
or  in  ovarian  tumours,  all  contain  the  same  form  of  glucosamin,  the  same 
form  of  reducing  substance. 

The  crystals  when  dissolved  in  water  are  dextrorotatory  and  readily 

reduce  Fehling. 

Table  showing  the  crystallographic  characters  of  glucosamin  as  obtained 
from  pseudo-muciH.  as  compared  with  that  obtained  from  other  sources 
{Schwantke's  analysis)  : 


n:p   :    c:r    I    c:q    <    c:p       e:p       e:q        p:q       p:q 
no:  iioiJoi:  ioiImi  :oiii»i  :  "o  ioi  :  iic  loi  :  on  no:  on  no.  on 


f  lobster 
shells 
fiydrochio  -.  sputum 
ride  from    I    mucin 
Vegg  alb. 
Pseudo-muci.i 


67°  48'!  67°  or 

67°46'  67°04' 
67°  53!  67=08' 


35°  331 59°  55' 65°  20' 


84=38' 


35°  18'  S9°53'  65°49|  7«°4o'|  84=  58' 
35°  29  I  59! 44'     -         —    I    - 


35°25'i59'56' 


43°  09' 

4*°  39' 
42°  5»' 


65°3«'l7«°3i'84°52' 42-49 


Paralbumen.— The   following  reactions  may  be  used  to 

identify  it  :  .    ,        1 

1.  Salkowski  recommends  the  following  test:  A  few  drops 
of  alcoholic  rosolic  acid  are  added  to  25  cc.  of  fluid  and,  after 
boiling,  drops  of  decinormal  H,SO,  are  added  till  the  colour 
becomes  yellow.  If  the  filtrate  after  boiling  is  cloudy,  there  is 
paralbumen  present. 

2.  Shake  the  residue  resulting  from  the  addition  of  alcohol  in 
excess,  with  hydrochloric  acid  (i  in  3).  and  boil.     On  cooling. 


40 


STUDIES  IN    I'UNCTURK-FLUIDS 


hi 


Troininer's  test  is  applit-d  and  tlu"  test  tiiln-  left  in  water.  A  red 
l)rerii)itate  means  paralbunun  or  mucin. 

.}.  Acetic  acid  does  not  precipitate  the  parall)umen. 

Mucin. — The  reactions  of  mucin  demand  a  l)rief  consideration 
in  ortier  that  it  may  he  distinguished  from  i)seudomucin,  for  this 
is  important.  Its  distinction  from  nucleo-alhumen  Ues  in  the  fact 
that  the  latter  contains  phospliorus  and  does  not  reduce  Fehling 
after  hydrolysis  ♦  while  mucin  contains  no  pho-iphorus,  and  does 
yield  a  reducing  tody. 

Otiiii'  fthifyerlies.      i.  Swt-lls  up  in  water  into  a  ^liiny  mass. 
.;.    Is  pri'cipitatiil  liy  acetic  acid,  insoluble  in  excess. 
,1.   The  solution  IS  claritied  liy  very  dilute  soda.      If  neutral    boilinfj  will 
not  precipitate  it. 

4.    Hydrolysis  with  an  alkali  converts  it  into  animal  num. 

3.    In  tissues  it  is  recognised  liy  staining  with  thionin  and  toluidine  lilue. 

The  significance  of  the  presence  of  mucin  in  a  fluid  is  that 
it  indicates  an  origin  either  from  a  nmcous  surface  or  from  some 
tissue  which  jx)ssesses  goblet  cells.  Therefore  if  present  in 
ix-ntoneal  fluid  it  means  that  there  must  be  secondary  growths 
from  a  papilliferous  or  colloid  tumour,  or  that  the  fluid  obtained 
by  puncture  has  come  from  within  a  papillomatous  cyst  of  the 
ovary. 

In  the  diagnosis  of  this  substance  one  has  to  bear  in  mind  the 
following  errors  or  sources  of  error  : 

In  the  first  place,  serosamucin,  which  has  some  similar 
reactions,  may  occur  in  an  inflammatory  jieritoneal  fluid. 

In  the  second  place,  both  sputum  and  saliva  may  contain 
mucin,  and  if  present  as  impurity,  would  lead  to  an  erroneous 
diagnosis  unless  the  [wssibility  of  such  contamination  be  excluded. 
Whereas  submaxillary  nmcin  contains  2^5  per  cent,  glucosamine, 
the  mucin  from  a  mucous  membrane  contains  35  per  cent,  of 
glucosamine  ;  moreover,  submaxillary  mucin  contains  chon- 
droitinsulphuric  acid,  just  as  does  the  mucoid  obtained  from 
cancers.  Of  course  such  details  cannot  be  used  clinically  for 
differentiating  the  mucins. 

*  Other   bodies    may   yield   a   reducing   substance   after   hydrolysis. 

especially  with  sulphuric  aci<l.     Thus,  paranucleins  do  so.  and  also  yield  an 

osazone  :    the  tame  is  true  of  nuclcohistonc.     Paranucleins  are  nucleins 

which  form  no  xanthin  bases  in  the  presence  of  acids,  while  true  nucleins 

do  so. 


THE  CHEMICAL  EXAMINATION   OF   PUNCTLKE-FLlins     4> 

A  sulwtance  allieil  to  mucin  has  been  tlescril)Ctl  as  occurring 
in  the  blood  by  Zanetti,  p:ichhol7.,  and  others. 

Thi-  chief  difficulty,  however.  Hes  in  differentiating  mucin 
troMi  mucoids,  which  inchide  colloid  sulistance.  jweudo-mucin, 
and  paralbumen.  However,  pseudo  mucin  is  not  precipitated 
by  acetic  acid,  though  it  comes  down  readily  in  the  presence  of 
excess  of  absolute  alcohol. 

The  reactions  of  this  body  have  been  given  abovr. 

The  paramucin  of  Mitjukoff  is  a  jelly-like  ma^s.  and  con- 
sequently hardly  calls  for  consideration,  though  it  is  often  found 
in  ovarian  cyst.  It  differs  from  pseudo-mucin  in  reducing  Fehling 
without  previous  treatment  with  acid. 

Paralbumen  is  only  imjK-rfectly  precipitated  by  acetic  acid, 
and  is  supposed  to  be  really  i^seudo-mucin  with  albumen  as  an 

impurity. 

The  mucin  of  bile  is  regarded  by  Landwehr  as  a  globulin 
mixed  with  bile  salts,  while  Paijkull  regards  it  as  a  nucleo- 
albumen. 


TABLE   V 
Mucins  in  Puncture-Fluids* 


Absent  in 


Present  in 


(2  Tuberculous  Pleurisies         3  Tuberculous  Pleurisies 
Effusion  secondary  to  Ab- 
dominal Cancer 
Renal 
"  Idiopathic  "  effusion 
Cardiac  Failure  (4  cases)         Empyema  (2  cases) 


Pericardial,  Cardiac  Failure 


Cardiac  Failure  (3  cases) 
Renal  Disease  1 3  cases) 
Sarcomatosis 

„    .  ,1  Ga^tric  Cancer 

Peritoneal    p.^creatic     Cancer     (not 
invading  peritoneum) 


Carcinomatosis 
Cardiac  Failure  (l  case) 

„         +  Renal  Disease  ( 1  case) 

Renal  Disease 


Cirrhosis  of  Liver  (2  cases)     Simple  Chronic  Peritonitis 
^Tubercular  Peritonitis 


Broad-ligament  Cyst 


Ovaiian  Cysts  (4  cases) 


Not  necetsarily  "  »ero»«niucin.' 


42 


STl.DIKS  IN    lUNCTURE-FLUIDS 


LECITHIN 


•  ii 


!  I. 


■ffi 


ii  i 


The  cht'iiiistry  of  lecithin  is  gratUially  Ix'coming  more  de- 
fined, and  the  fact  that  there  are  niany  substances  p.esent  in 
the  \KH\y  which  can  In*  f,'rou|)ed  under  the  name  of  "  ii|)oicls  " 
or  of  "  pliosphatids,"  taking  lecithin  as  a  basis,  is  being  realised 
as  a  result  of  several  recent  iinjmrtant  researches.  There  is, 
in  addition,  an  increasing  knowledge  of  the  physiological  and 
l)athological  |)ro|H'rties  of  this  sulwtance.  Since  this  literature 
is  largely  inaccessible  to  the  general  reader,  it  may  Ix;  usefully 
discussed,  with  esjK-cial  reference  to  the  influence  which  the 
pro|H'rties  of  lecithin  have  on  the  nature  and  constitution  of 
puncture-fluids. 

The  importance  of  lecithin  is  shown  by  the  following  dis- 
coveries :  It  i)lays  a  somewhat  obscure  part  in  the  processes  of 
immunity  ;  thus  it  is  essential  to  cobra-venom  in  the  hemolytic 
process  characteristic  of  )X)isoning  by  snake-bite.*  It  plays  an 
inijwrtant  part  in  the  process  of  i)roduction  of  anccsthesia,  since 
it  is  assumed  that  lecithin  renders  the  anaesthetic  readily  i)er- 
meable  into  nerve-cells,  and  calculations  have  been  made  by 
which  laws  governing  the  distribution  of  anjesthetic  over  nerve- 
cells  could  be  formulated. t  Thirdly,  lecithin  is  presumably 
the  source  of  cholin  (see  p.  170),  whose  presence  in  cerebrospinal 
fluid  has  been  found  by  Halliburton  to  be  pathognomonic  of 
organic  nervous  disease.  Fourthly,  lecithin  is  an  essential  con- 
stituent of  all  growing  tissues  |  and  in  bone-marrow.  §  Fifthly, 
it  is  frequently  associated  with  cholesterin,  which  leads  one  to 
susi^ect  some  subtle  relation  to  exist  between  the  functions  of 
these  two  substances.  Their  association  recalls  the  phenomena 
of  symbiosis  in  living  organisms,  and  there  are  several  observa- 
tions in  the  literature  which  show  that  the  two  substances  may 
act  in  combination  better  than  when  kept  separate.  Thus,  both 
bodies  may  take  a  part  in  the  hctmolytic  action  of  bile.y  Sixthly, 
the  suggestion  that  pseudo-globulin  retards  the  action  of  certain 
lysins  may  be  brought  into  line  with  Joachim's  discovery  that 
lecithin  is  mainly  attached  to  the  pseudo-globulin  fraction  in 
ascitic  fluids  (and  therefore  presumably  also  in  the  blood-serum). 

*  ilorf;enroth  ;  Keys. 

t   Researches  on  the  distribution-coefficient  by'Overtoi. 

I  Francliini.  §  Otolski ;   Ghkin.  ||  Gustav  Bayer.        j 


PI 

Ml » 


THE   CHKMUAL   EXAMINATION   OK   PI  NCTURE-HAIDS      43 

Lastly,  the  imixjrtant  discovery  l«as  recently  Jx'en  made  by 
Purges  that  if  a  o'i  jht  cent,  aqueous  susi)ension  of  lecithin  U- 
ulded  in  equal  volume  to  the  l.l(K>d-serum  of  a  syphilitic  subject, 
there  will  app-ar  atliKCulent  precipitate  after  hve  hours'  inruba- 
tion  at  J7  C.  The  reaction  li.is.  so  far.  never  Ix-en  obtamtd  m  the 
case  of  a  non-syphilitic  subject. 

Some  of  these  ixnnts  ilen.and  further  consideration.  Thus,  we 
may  refer  to  the  presence  of  lecithin  m  growu.g  tissues.*  among 
which  a  developing  hen's  egg  forms  a  suitable  exanq-le,  for  its 
yolk  contains  a  large  quantity  of  lecithin,  an.l  may  be  said  to  l« 
a  reixjsitory  for  that  substance. 

The  growing  embryo  withm  this  egg  contains,  of  cours.-,  a 
large  quantity  of  nucleic  acids  in  the  cells  which  are  so  rapuUy 
\^mg  formed,  and  it  becomes  of  interest  to  study  the  formula; 
of  nucleic  acid  and  lecithm  in  order  to  ascertain  if  there  l)e  any 
sort  of  relation  between  them.  If  we  take  a-guanylic  acid  as  an 
example  of  a  nucleic  acid  since  a  graphic  formula  of  this  substance 
has  been  made  out  by  Bang  and  Raaschon,  we  have- 

Lecithin. 

OH 

C  H  N(CH,),OH-0-I'.-0-C,H»=.(C„H;„-,a), 
Vjnj.'v-'-ju  fatty  acid. 

a-GuANVLic  Acid. 
OH       OH 

c,H.N.-O^P;^0-C.a(OH) .  Cj,H.A 

o 

C,H,N»-0-l'-0-C,Hs(OH)   C.H.Oi 

o  o 

CjH.N.-0-P-0-C,H5(0H)CjH.Pi 

6 
C»H,N.-0-  P-0-C,Hs(  OH  )C,H,0» 

OH  OH 
The  symbols  printed  in    thick   letters    will   show  at  once 

♦  It  is  most  likely  ihat  much  of  the  conf,r-ir.:  which  ha«  ''-;-«y=;.»° 
the  pre^ile  constitution  of  lecithin  is  due  to  its  having  been  mamly  studied 
in  this  material  rather  than  in  the  various  adult  tissues. 


44 


STUDIES   IX   ri'NCTURE-FLUIDS 


41? 


U  i 

III 


how  the  formula  of  lecithin  can  he  fitted  into  that  of  the 
nucleic  acid,  or,  more  correctly,  that  the  two  suhstances  are  built 
up  in  a  similar  manner,  so  that  the  nucleic  acid  might  readily 
give  rise  to  lecithin  in  the  course  of  metabolic  breakdown.  It 
will  thus  be  seen  that  we  have  here  only  another  example  of 
what  must  Ix"  going  on  all  over  the  body  during  life,  producing 
the  redundancies  of  ])hysiological  chemistry,  since  a  few  sub- 
stances of  very  complex  constitution  will  suffice  to  allow  of  the 
appearances  of  an  endless  number  of  breakdown  products 
(vital  as  well  as  lalwratory)  which  might  be  looked  upon  either 
as  post-  or  pre-formed  in  the  molecule.  It  is  the  determination 
of  whether  we  are  dealing  with  the  one  or  the  other  which  is  the 
most  difficult  of  the  problems  of  physiological  chemistry. 
But  enough  has  been  said  on  this  subject  in  the  first  few  pages. 

The  interest  which  the  decision  of  the  structure  of  the  lecithin 
molecule  har.  to  us  just  at  present  lies  in  the  fact  that  those  two 
formulc-E  allow  us  to  understand  (vaguely,  it  is  true)  the  vital 
part  which  lecithin  plays.  It  is  remarkable  to  find  that  lecithin 
has  a  considerable  tenacity  of  its  couiplex  structure  as  long  as  it 
remains  part  and  parcel  of  the  living  cell. 

An  additional  fact  about  the  physiology  of  lecithin  is  supplied 
by  other  recent  researches,  namely,  that  it  plays  a  part  in  the 
assimilation  of  food-substances  and  in  the  development  of  cell- 
ferments.  There  has  been  found  a  marked  similarity  in  the 
'.nteraction  between  ferments  and  lecithin  to  that  between 
ferments  and  mastic. 

The  existence  of  lecithin  in  bone  marrows  suggests  an  explana- 
tion for  the  undoubted  effect  which  X  rays  have  in  the  treatment 
of  Icucocythaemia. 

In  order  to  arrive  at  a  conception  of  the  chemistry  of  lecithin  it  will 
be  convenient  to  discuss  the  subject  from  the  historical  point  of  view. 

There  are  two  periods  in  the  development  of  the  knowledge  of  this 
subji-ct,*  a  prc-Thudichum  period,  anti  t  the  period  started  by  Thudichum. 
We  may  say  that  although  fatty  substances  containing  phosphorus  were 
known  to  Fourcry,  Vauquelin  (i793).  Couerbe.  and  Freny(i84o),  the  name 
lecithin  was  not  invented  till  Gobley  had  made  his  investigations  (1846)  on 
<'gg-y""<'  whence  he  obtained  glycerophosphoric  acid.  Four  years  later 
Liebreich  had  come  to  consider  that  a  body  which  he  called  "  protagon  " 
•iiust  be  the  mother-substance  of  lecithin,  a  conception  which  finished  in 
a  complete  proof  as  a  result  of  modern  research  of  the  fact  that  there  is  no 


Danilewsky. 


t  Michaclis  and  Rona. 


THK  CHEMICAL   EXAMINATION   OF   PUNCTURE-FLUIDS     45 

ontity  "  lecithin."  but  that  there  are  a  numberof  different  fatty  phosphorus 
containing  bo<iies  present   in.   say.  nerve-substance,   but   yet   able   to  bo 

isolated  by  suitable  procedures.  •    .u     . 

In  and  about  the  year  ,846  we  find  several  names  prominent  in  the  story 
ol  the  research  into  lecithin-Hoppe-Seyler.  his  pupils.  Diakonow  and 
><tecker  These  observers  showeil  in  the  first  place  tl.ct  protagon  was  not 
the  onlv  phosphorus-containing  substance  in  the  bmly.  and.  in  the  secon. 
place  they  not  only  obtained  pure  lecithin,  but  also  showed  how  cholin  and 
Klycerophosphoric  acid  combine  to  form  lecithin  when  in  association  with 

oleic  acid. 

In  1876  we  come  to  the  second  perio<l  of  study,  when  riuidichum  began 
to  publish  his  researches,  ultimately,  in  1 901.  culminating  in  a  most  thorougli 
account  of  all  the  phosphorus-containing  fats  which  occur  in  the  brain 
He  grouped  them  all  under  the  heading  of  "  phosphatids,"  and  subdivided 
these  into  cerebrosides.  cerebrinazids.  and    amitlolipoids.      Although  this 
investigator  planned  out  methods  of  (piantitative  analysis  and  means  o 
.listinguishing    all    these    bodies,    and    although    he    adversely   criticised 
Hergell's  suggestion  that  phosphatids  could  be  estimated  as  cadmium  com- 
i)ounds    it  may  be  safely  said  that  neither  Thudichum  nor  any  one  else- 
has  yet  succeeded  in  devising  a  scheme  for  quantitative  analysis  which 
IS  above  criticism.     The  methods  which  can  be  adopted  arc  only  endowed 
with  approximate  accuracy.  ,  .  .    ,     .,.  .     . 

I'crhaps  the  presence  of  lecoriti  *  in  the  mixtures  in  which  lecithin  has 
been  sought  will  explain  to  some  the  confusion  which  has  arisen  in  the 
(uiantitative  analyses.  We  must,  however,  regard  all  opinions  about  these 
bo<lies  as  at  present  only  temporary,  merely  remembering  that  the  word 
"  lecithin  "  does  not  represent  an  entity,  but  represents  many  closely  allied 
substances. 

The  difference  between  one  lecithin  and  another  which  has 
been  utilised  by  Erlandsen  as  a  basis  for  classification  consists 
in  the  ratio  which  the  nitrogen  bears  to  the  phosphorus.  We 
may  then  arrive  at  the  following  classification  of  lecithins  : 

1.  Monamido-monophosphatids  (N  :  P  =  i  :  i),  e.g.  lecithin, 
cephahn.     These  contain  two  latty  radicles. 

2.  Monamido-diphosphatids  (N  :  P  =  i  :  2),  e.g.  criiorin- 
three  fatty  radicles  (unsaturated  and  easily  oxidised)  +  glycero- 
phosphoric  acid  +  alkaloid-like  base. 

J.  Diamido-monophosphatids  (N  :  P  =  2  :  i).  e.g.  Thudi- 
chum's  amidomyelin  and  sphingomyelin.  These  only  occur  in  the 
body  combined,  say,  with  albumen  (lecithin-albumen). 

4.  Diamido-diphosphatids   (N  :  P  =  2  :  2). 

It  will  be  seen  from  these  varying  ratios  that  the  classification 
does  not  provide  us  with  a  means  of  determining  how  much  of 
each  variety  may  be  present  in  a  mixture  of  phosphatids.     A 

*  Drechsel-Baldi.     This  substance  is  briefly  discussed  below. 


46 


STUDIES   IN    PUNCTURE-FLUIDS 


II 


U 


N 


complicated  series  of  separations  by  fractionation  with  acetone, 
ether,  and  alcohol  has  been  utilised  for  this  purpose,  and  the  only 
means  of  identifying  the  body  so  isolated  consists  in  the  ordinary 
ultimate  organic  analysis.  Such  a  procedure  is  only  of  interest  to 
the  student,  and  for  this  reason  the  method  published  by  Stern 
and  Thierfelder  last  year  is  given  below. 

A  procedure  such  as  this  gives  a  fairly  correct  estimate  of  the 
amount  of  each  phosphatid  present ;  but  in  the  study  of,  say,  ascitic 
fluid  the  presence  of  so  many  nitrogenous  bodies  would  involve 
very  careful  preliminary  separations  in  order  to  arrive  at  anything 
like  a  pure  enough  substance  for  analysis.  Before  discussing  the 
methods  of  detection  and  analysis  the  following  account  of  the 
properties  of  lecithin  will  be  advantageous  : 

Prof)crties  and  Confirmatory  Tests. — Lecithin  is  a  monophos- 
phatid  which  can  be  obtained  in  the  form  of  a  very  hygroscopic 
mass  which  is  insoluble  in  acetone,  but  soluble  in  absolute  alcohol. 
It  can  be  thrown  out  of  its  alcoholic  solution  by  both  cadmium 
and  platinum,  in  the  form  of  addition-compounds. 

It  gives  Pettenkofer's  reaction  with  concentrated  H2SO4. 

It  meltsat  about  68^  C.,and  begins  to  decompose  at  70°  C.the 
decomposition  products  depending  to  a  certain  extent  on  the 
exact  composition  of  the  lecithin.  While  on  the  one  hand  lecithin 
is  made  out  to  consist  of  cholin,  glyccrophosphoric  acid  and  a 
fatty  acid,  the  latter  may  be  sometimes  distearic  acid,  sometimes 
palmitic  acid,  and  sometimes  dioleic  acid.  As  a  rule,  each  of  these 
occurs  in  one  given  sample  of  lecithin,  the  exact  proportions  vary- 
ing, and  giving  rise  to  variations  in  ultimate  analysis,  though 
differences  in  solubility  in  absolute  alcohol  enable  them  to  be 
separated  by  fractionation.  The  differences  in  content  and 
variety  of  fatty  acid  explain  some  of  the  differences  in  physical 
properties.  As  a  rule,  lecithin  is  a  waxy  mass  which  is  softer 
the  more  oleic  acid  there  is,  and,  on  the  other  hand,  special 
methods  of  extraction  and  purification  may  yield  it  in  the  form  of 
a  powder.  It  is  only  crystalline  when  salts  have  been  formed 
with  it,  the  crystals  being  generally  in  the  form  of  thin 
microscopic  hexagonal  plates. 

The  substance  may  also  have  allotropic  forms,  for  Thudichum 
distinguished  between  a  water-soluble  lecithin  and  a  lecithin 
insoluble  in  water,  the  latter  form  being  produced  if  it  be  extracted 
with  alcohol  and  dried. 


THE  CHEMICAL  EXAMINATION   OF   PUNCTURE-FLUIDS     47 

Then  again,  there  are  optical  differences  between  different 
forms  of  lecithin,  for  while  the  compound  as  usually  obtamed  is 
dextrorotatory  K  2,^-  +  iX3-ix-4=).  theaction  o^.^t-Psm  on 
it  results  in  a  l^vorotatory  form.  But  besides  this  here  is  a 
racemic  form,  produced  by  heating  the  dextrorotatory  form  with 
ten  times  its  bulk  of  absolute  alcohol  for  5  to  6  hours.  This 
variation  in  optical  activity  has  been  explained  by  Ulpiani  in 
190 1  by  the  following  formulae  : 

CH...-0- Fatty  acid 

CH  -PO,H-Cholin 

CH,-0- Fatty  acid 

Racemic. 


CH.-O-Fatty 

I  acid 

H.  CO -Fatty  acid 

CH,-O.PO,H- 

Cholin 
Dextrorotatory 


CH.,-0- Fatty 
I  acid 


Fatty  acid -O-CH 


CH,.0-O.PO,H- 
Cholin 
LsEVorotatory. 


The  racemic  form  is  seen  to  be  quite  symmetrical. 

Yet  another  consideration.     If  we  compare  the  formula  o 
cholin  and  neurin  we  see  that  in  each  case  there  are  three  methyl 
groups  attached  to  the  nitrogen  of  ammonia,  while  in  chohn  the 


CH5-0H 

CH,-N-(CH,),.OH 
Cholin. 


CH, 

CH-N-(CH,),.OH 
Neurin. 


remaining  H  atom  is  replaced  by  the  group  C,H..  OH  instead 
of  bv  C..H3,  which  completes  the  formula  of  neur-.i  It  is 
reasonable  to  suppose  that  if  a  lipoid  (phosphatid)  can  be  formed 
of  cholin.  another  may  exist  which  is  formed  of  the  aUied  neurm. 
The  association  of  the  three  substances  in  the  phosphorus- 
containing  material  of  the  brain  suggests  that  they  may  all  be 
associated  and  possibly  may  be  all  in  some  kind  of  chemical 
association.  Not  only  this,  but  the  discovery  of  a  number 
of  bodies  allied  to  cholin  by  Kutscher  of  Marburg  (1907)  m 
the  urine,  opens  up  a  large  field  of  possibilities.     These  new 

I  methylguanidin  ;  2.  novain  ;  3.  reductonovaine  (is  to 
nova'in  as  neurin  is  to  cholin) ;  4.  methylpyridm  chloride  ;  5. 
gynesin  ;   6,  mingin  ;  7.  vidiatin  ;  8,  obhtin  .  9.  neosm 

All  these  bodies  yield  trimethylamine  on  decomposition,  and 
form  platinum  salts,  which  enable  their  identification.  Up  to  the 
present  they  h.ave  onlv  been  met  with  in  meat  extract,  but  their 
excretion  by  the  urine  suggests  that  they  may  play  an  important 


48 


STUDIES  IN   PUNCTURE-FLUIDS 


I 


j>art  in  j)uiin  metabolism,  and,  inasmuch  as  two  bases  are  asso- 
ciated with  lecithin,  these  other  bases  may  at  some  period  of  their 
ionnation  come  into  relation  with  the  same  lipoid. 

The  iinp-ort.ince  of  these  considerations  lies  in  the  light  which 
they  throw  on  i  ertain  physiological  questions.  Thus,  the  enzymes 
of  the  aininal  l)ody  have  been  found  by  Paul  Mayer  to  act 
entirely  differently  on  de.viro-  from  htvo-rotatory  lecithin. 
Possibly  its  action  in  activating  cobra-venom  will  depend  to 
some  t.'vient  on  its  oj)ticaI  character. 

In  '.he'apeutics,  lecithin  may  be  beneficial.  Claude  and 
Za.\y,  speaking  at  Paris  in  i()oi,  showed  that  lecithin  has  a 
favourable  inHuence  on  the  nutrition  of  a  tuberculous  subject  by 
increasing  the  energy  of  metabolism,*  though  its  use  did  not 
prevent  the  advance  of  the  disease. 

The  association  of  cholesterin  with  lecithin  is  a  fact  of  very 
great  interest,  and  has  engaged  the  attention  of  Dr.  Craven  Moore, 
v.ho  considers  that  cholesterin  exists  in  the  cell  in  a  colloidal 
state,  through  the  agency  of  lecithin.  When  the  latter  under- 
goes dissolution,  the  more  stable  cholesterin  becomes  unable  to 
maintain  its  colloidal  condition  unless  fatty  acids  or  their  deriva- 
tives be  jiresent,  and  it  then  gradually  separates  out  in  crystalline 
form. 

The  observation  of  Pascucci  shows  up  what  I  term  the  sym- 
biotic relations  between  cholesterin  and  lecithin.  The  addition 
of  cholesterin  to  a  hicmolysin  neutralises  the  activity  of  the 
latter,  while  lecithin  has  no  action,  the  varying  proportion  of 
lecithin  and  cholesterin  thus  affording  a  means  of  regulating 
the  effect  of  hscmolytic  substances  on  the  cell.  If  the  OH  groups 
of  cholesterin  l)e  rendered  inert,  this  neutralising  property  is 
lost. 

Lecithin  and  cholesterin  together  form  means  by  which 
substances  otherwise  unable  to  }x;netrate  the  cell-envelope 
become  enabled  to  do  so. 

Methods  of  Detection  and  of  Extraction  of  Lecithin. 
— Otolski  made  use  of  the  separating  power  of  an  excess  of 
(j()  per  cent,  alcohol ;  but  if  we  search  through  his  figures,  they  do 
not  seem  to  show  very  constant  N  :  P  ratios. 

Manasse   used   warm  absolute   alcohol   for    extracting   the 

•  Glyccrophosphoric  acid  appears  in  the  urine  when  lecithin  is  taken. 


irx 


TIIK   CIIKMICAL   EXAMINATION   OF    PUNCTURE-FLUIDS      49 

l.x-hhin.  and  cnployed  Salkowsk.'s  method  of  .Ictecting 
phosphorus  m  the  evaporated  extract.  This  method  .s  smiple 
and  apparently  sufficient  for  clinical  purposes. 

In  slveral  of  mv  own  specimens  I  hav^  used  the  prec.pUate 
w,th  ammonmm  sulphate   (Table   B)   a        ..pphe.l  Salkowski  s 
,.ethod  of  incmeration  for  phosphorus.     If  known  -e.«hts  are 
used   this  method  can  be  made  a  quantitative  one.  although  it 
nuist'  be  remembered  that  all  the  lecithin  present  is  not  necessarily 
...timated,  as  not  all  of  it  may  be  in  association  with  the  globulin 
If  this  method  be  adopted  we  shall  be  able  to  endeavour  to  detec 
the  presence  of  this  substance  with  the  same  quantity  of  fluid 
that   was   used  for   globulin-an   important   point   when  only 
moderate  amounts  of  fluid  are  available  for  analysis. 

The  absolute  proof  that  a  substance  .s  lecth.n  will  involve  an  f}^^^'^^ 
of  th  X  P  ratio,  an  estimation  of  the  rotatory  power,  a  preparation  of  the 
r  "'Active  cacl,..un,  salts,  and  finally  the  '^^-^^J^f^^^  °' 
.i.tection    see  v    i/i).  glycerophosphonc  acid,  and  of  fatt>  acicis. 

/.a^r"L.U  //.</-..  A^eighed  quantity  of  substa.-.e  is  dried  at 
,.o'lT  there  be  a  negligible  residue  there  is  no  inorganic  phosphorus. 
0,Lrwisei™lue  ,s  fusc'l  with  soda  and  saltpetre  in  a  platinum 
'thT     1  of  a  blowpipe.     The  residue  should  be  white,  and  is  dissolved  in 

the  addition  of  ammonia,  then  mineral  phosphates  are  present  [Ca  PO,)., 

"'Thf oJiS^ortion   is  treated   with   ammonium   molvbdate,  and  the 
r  Jting  ^recipUate  may  be  weighed  in  order  to  estimate  the  quantity  of 

^'°SMr.n.  of  precipitate  corresponds  to  00175  gm.  lecithin.* 

T^e  obV-ction^to  this  simple  method  is  that  one  cannot  well  distinguish 
between  the  organic  and  the  inorganic  phosphorus.  ,.     ,    ,u 

.The  simplest  procedure  then  would  be  to  add  three  times  the  bulk 
of  .uiicl  used  of'absolute  alcohol,  and  wash  the  residue  well  ^^^orcj..^^^-^ 
L  t  to  dryness.  The  residue  is  then  taken  up  with  water,  and  shaken 
"peatllly  with  ether.  The  ethereal  extract  is  a"--'  -/^>:,-t,tc 
residue  fused  with  3  parts  KNO.  and  i  part  sodium  carbonate.  The  white 
"s  u  r  Lived  in  a  trace  of  water  and  nitric  acid  added.  Ammonium 
moUbdate  is  added  ^avoiding  e.xcess)  and  the  precipitate  weighed  as  in 

""■''."^^tlll  moreaccurate  method.s  thatof  Neumann.  500-.  «u id  are 
treated  with  pure  nitric  acid  and  gra.lually  poured  into  a  round-bottomed 
tla^kcontiniSg  30CC.  of  boiling  nitric  acid.     There  should  never  be  more 

.  It  is  assumed  that  .  gm.  lecithin  contains  00384  gm.  phosphorus. 


so 


STUDIES   IN    PUNCTUKE-KLUIDS 


.Hi, 


than  irx)  cc.  of  fluid  in  tin-  flask  at  once.  The  fluid  can  then  In-  rapidly 
rc<luci-d  to  a  small  bulk.  5-10  cc.  of  a  inixturcof  cipial  parts  of  pure  nitric 
and  s\ilphuric  acids  are  added,  moderate  heat  in  a  draught-chamber  being 
used.  .Additional  (piantities  of  tlie  acid  mixture  are  added  till  a  litre  has 
been  used,  and  the  fluid  can  then  be  allowed  to  cool.  The  fluid  in  the 
flask  shouUl  now  be  as  clear  as  water.  ( Rapid  method  of  oxidising  organic 
matter  in  any  flui.l,  perhaps  especially  useful  for  urine.) 

For  each  40  cc.  of  resi<lual  fluid  add  water  to  150  cc.  and  50  cc.  of  am- 
monium nitrate.  Heat  till  bubbles  rise,  and  then  add  40CC.  of  ammonium 
niolybdate.  The  precipitate  of  ammonium  phosphomolybdatc  is  thorough- 
ly shaken  till  ^ramdar  and  left  a  quarter  of  an  hour,  and  then  washed  by 
decantation  till  the  washings  cease  to  be  acid.  The  residue  on  the  filter  is  re- 
turned to  the  flask,  i  50CC.  water  are  added,  and  seminormal  soda  added  from 
a  burette  till  solution  occurs.  5  or  6  cc.  over  this  point  are  added,  noting  the 
number  of  centimetres  used.  Boil  till  ammonia  cease.s  to  come  off,  and 
then  titrate  with  seminormal  acid  against  phenolphthalein.  (The  number 
of  centimetres  of  so<la  used — number  of  centimetres  of  acid —  -t-  I'zbS  gives 
P.O.,  in  milligrammes.) 

4.  The  complicated  but  more  accurate  mcthotl.s. — (a)  ErlanJseii  first 
lined  the  material  in  a  current  of  air  for  several  hours,  and  then  in  vacuo. 
The  powdery  mass  was  extracted  w  ith  ether,  and  the  final  extraction  treated 
with  alcohol.  The  alcohol  fraction  was  made  to  yield  the  phosphatids  by 
successive  extraction  with  ether  and  acetone,  while  the  ether  fraction  was 
treated  with  acetone  to  extract  lecithin,  cruorin,  etc. 

('')  The  details  of  this  niethml  arelengthy  and  cannot  be  dealt  with  in  this 
place.  .\  tal)le  (pi>.  5.2-5.?)  showing  Stent  an!  Tlierfeldct's  scheme  is  given, 
however,  in  order  to  give  some  idea  of  the  lengthy  procedure  necessary  in 
order  to  make  accurate  re.searches  on  this  subject.  The  special  feature 
of  their  methcxl  was  the  carrying  out  of  the  metho<ls  in  the  dark  in  an 
atmosphere  of  CO.. 

(c)  Manasse's  methcnl  is  similar  to  that  of  Erlandsen  (1906). 

It  mu.st  again  be  emphasised  that  even  these  quantitative  methods 
do  not  give  absolutely  correct  figures,  owing  to  the  loss  that  necessarily 
takes  place  during  the  extraction  processes.  Besides,  it  is  not  possible  to 
absolutely  separate  the  monamidophosphatids  from  thedianiinophosphatids. 

The  accompanying  table  shows  that  the  jnocess  is  essentially  one  of 
fractionation  with  different  solvents,  some  of  the  phosphatids  being  more 
insoluble  than  others. 

There  is  an  additional  source  of  error  in  the  fact  that  the  fluids  which 
we  are  concerned  with  may  contain  nucleic  acids  or  their  derivatives,  i.e. 
other  phosphorus-containing  substances,  and  these  will  work  out  as  lecithin 
in  the  estin\ation  as  jihosphorus.  In  the  mcthotls  of  series  4,  however, 
the  substances  are  identitiod  by  their  percentage  compositiot.  In  spite 
of  the  errors,  the  last  series  (4)  are  as  accurate  perhaps  as  one  can  hope 
for. 

In  respect  to  tiie  puncture-fluids  it  was  thought  possible  to  identify 
certain  of  these  complex  substances  by  applying  the  tests  which  arc  u.sed 
.Ts  micrn-chcmita!  reactions.  The  difficulties  so  far  have  been  in.superable. 
The  fact  that  lecithin  crystals  do  not  stain  with  osmic  acid  after  previous 
fixation   with  potassium  bichromate  has  not  been   found  available  as  a 


i  I 


EXAMINATION   OF    PUNCTURE-FLUIDS      5I 


TIIK   CHEMICAL 

.  ■    *    .      Th.TP  can  be  no  douht  that  if  such  reactions  couUl  be 
:;r;,..„cture-fluias  for  ^Hn-cai  pug^^es  very  con^.l^.^  ^^^^  ^^  ^^^  ^^^.^ 

f.n.hngofjeconn  ^ »     ^t;     "    ^se.  as  C,.H,.N..r.SO.Na,.     It   . 

1,.   formula   has    bttn  ^'7'^"  '>  ,  (o^ms  a  slimy  mass  in  the 

'  '■""^'  ^;'t;:r'^''r  ti^  -:S  l^e^:::  .1:  abnuy  to  Lluce  alUaline 
presence  «« -^^^^^  j''^  ^  .,  prec.pitatal  by  strong  salt  solut.ons  and  by 
copper  ^"'Py-»^'  ;''°^"f  ;;„  »,^,e  the  prc-c.p.tate  is  soluble  m  excess  of 

;r  r:::r.h^.;::t^  .uh  a;^-^- — t-™  stcompouna 
of  s:::f:s.^S=:A::tnbt::::n;;^a.on^-n;.-  -^ — 

tX::..  a  mature  of  n.a^-^ -;;  ZT^t::.^n  .n  very 
just  as  act.v.ty  of  resea  ch  on  K.  th.n  ^^^^^  ^^    _^  ^^  ^^^ 

n,any  t.ssues^  ^°;^^^T  blood,  and  m  the  suprarenals.  It  is  worthy 
are  the  spleen,  the  bram.  inc  considerable   amount    of 

"'  r  Wh  ttrSerrtisatrat^d  or  not  has  not  been  made  out. 
U-c.thm.     \Vhether  ^holesterm  is  ^ji^     to  Jacobsen.   Hennques 

However,  it  is  important  to  note  ha  -^^^^J  \.^^,,,,,,  ,,  jecorm. 
and  Kolisch.  the  glucose  of  the  Woo<l  may  p  >        ..^traction  of  the 

although  It  has  to  be  admitted  that  '".^'^'-'^f  ""^^^^^.j  ^^^h  the  ether, 
blood  w.th  ether  son.  free-  glucose  -^J^^^Xlt^:  otthe  extreme  care 
an<l  thus  give  r.se  to  an  error      * t  'S ^  ;„;„„,  ^,  to  what  sub- 

wh.ch  is  necessary  before  one  <o'^'""f  *'\^">  ^  ^,,4^  It  bears  out 
stances  are  and  what  -  -t  prese^^^^^^^^^^^      ^n^^  ^.^.^^  ^^^  ,^ 

the  view  that  many  of  the  ^^  ^^  f°;;',,.,„it  of  decomposition  of  the 
detected  ,n  a  body  flu.d  may  -  7;,;'>^  '^XU^^ed  to  definitely  settle 
proteuls  which  are  present.  J^^^"' ^^^^'J^ination.  and  he  comes  to  the 
th.s  problem  of  the  jecorm  -"'  ^^bv  "thm  as  a  solid  solufon  or 
conclusion  that  the  glucose  is  reta  ned  ^  it  j^^,.       ^^^^  ^t  is  a 

possibly  by  adsorption.  =»'*Jough  h^  ad-      th     IM^^^^^^^         .^   ^^^^^^^, 

rr^re::::"';,  ^t.  ;::^n:  a„d  says  they  Le  essentia,  con- 

^^'rr:^  that  If  ^-^-^-sx^^^^^^^ 

sugar  from  its  combinations    it  '"■B  >t  ^^P^^«   '^^,  ^^i.l  experiments 

,W  »"d.*r™c.  Wn«  .1...  il  gl«co--  I.  prc«..,  *■  l.-moly.,.  Ukc. 
place  very  much  more  rapidly. 


52 


STTMES   IN    MNelUKK-I-LUinS 


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THE  CUKMICAL   EXAMINATION   OF    I'UNCTLRE-KLUIDS 


53 


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»  ^  41    C    c 
C    '-    O    I. 


li! 


54 


STUDIES   IN    I'UNCTUKE-KLUIDS 
lAHLF.   VI 

I,K  IIIIIN    IN    ItoDV    FiflDS 


Kliiid. 


Uiaiase. 


lecithin. 


I'Uiiral     . 
I'tritontal 

Ovarian  C'v>l 


Inllanimatory, 

(AlKlcminal  Cancer)  ... 
Chronic  Kll'iision  (nature?) 

Kfnal  Disease 

J't  fitoneal  Cariinoinatobis 
rnilcibiilar  Cirrhosis     ... 
Kcnal  Disease    .  . 
Cardiac  Failure  ... 
Tubercular  IVritonitis  ... 
I'nilocii'ar  Cyst... 
Kroad  l.inamcnt  Cyst   ... 


Trace. 

Conspicuous 

I'rescnt. 


Absent. 


Absent. 
Present. 


Tlie  Study  of  the  jircscncc  of  lecithin  in  body  fluids  may  be 
saitl  to  date  from  Joachim's  investigations  in  1903.  when  he 
tvas  endeavouring  to  find  the  cause  of  the  turbidity  of  certain 
ascitic  tUiids.  In  one  special  case  studied  by  him  the  patient 
was  suffering  from  cirrhosis  of  the  liver,  and  the  fluid  which  had 
been  poured  out  into  the  abdomen  was  turbid,  though  no  fat  was 
present.  The  essence  of  this  study  lay  in  the  fact  that  pseudo- 
globulin  was  found  to  be  present  in  abumlance.  and  that  with 
this  pseudo-globulin  there  was  associated  lecithin.  That  this 
was  the  cause  of  the  milkiness  was  proved  by  the  fact  that 
dialysis  gave  a  clear  fluid,  and  that  the  residue  contained  lecithin, 
while  the  clear  fluid  did  not.  The  lecithin  was  extracted  by  the 
use  of  ether,  and  the  extract  tested  for  jihosphorus. 

It  was  found  that  only  the  pseudo-globulin  fraction  contains 
phosphorus,  namely,  ^-45  gm.  in  every  litre  of  ascitic  fluid, 
which  corresponds  to  035  gm.  lecithin.' 

Jolles  records  a  case  in  which  the  peritoneal  fluid  (disease 
not  stated)  contained  abundance  of  lecithin. 

These  observations  proved  beyond  doubt  that  lecithin  may 
occur  in  ascitic  fluids,  and  would  be  the  cause  of  the  turbidity. 
Moreover,  it  will  be  noted  that  this  occurred  in  a  case  of  effusion 
due  to  cirrhosis  of  the  liver.  It  became  a  matter  of  no  little 
interest   to   know   if  lecithin   occurred   in   other  fluids  besides 

♦  The  precipitate  resulting  on  ailding  J  vol.  of  sat.  .Xm.SO,  consisted 
o!  vuslulrtilin,  and  if  the  tiltratf  !••'■  hM  -;aturat«l  .og.iin  with  Am  SO^  a 
])rctipitatf  of  pseudo-globulin  results  which  is  soluble  in  sodium  chloride 
and  sodium  hydrate  solutions. 


TIIK  CHEMICAL   EXAMINATION   OF    PUNCTURE- H.UII'S      55 

ascitic  fluid,  ana  if  it  occurred  in  ascitic  fluid  under  any  other 

conditions.  .     »    i 

The  actual  diagnostic  in»i>ortance  which  Js  to  be  ;it  a.  liea 
to  the  occurrence  of  lecithin  in  a  body  fluid  can  hardly  be  made 
out  from  so  few  examples,  although  one  .oj^es  to  have  shown 
that  the  question  may  be  of  use  to  the  clinician. 

The  Diazoreaction.-This  reaction,  which  has  been  applied 
to  the  study  of  urine  under  certain  febrile  conditions,  was  care- 
fully studied  bv  Clemens  in  1904.  who  found  that  the  bodies 
which  are  responsible  for  the  reaction  are  precipitated  by  basic 
lead  acetate  and  are  insoluble  in  alcohol.  Tyrosin  and  histidin 
both  give  the  reaction,  and  as  the  former  may  be  present  in  a 
puncture-fluid,  it  was  thought  that  this  test  might  give  usefu 
results  in  puncture-fluids,  esi^cially  when  the  test,  as  applied 
for  the  detection  of  histidin,  is  extremely  delicate. 

The  results  of  the  experiments  showed,  however,  that  it  was 
very  rarely  present.     It  was  obtained  distinctly  m  a  case  of 
ijleural   efiasion   associated  with  abdominal  sarcoma,  and  als<) 
in  the  fluid  from  a  tuberculous  pleurisy.     In  only  two  i^ritoneal 
fluids  was  it  found-namely,  one  from  a  case  of  polyorrhomenitis 
and  another  from  a  case  of  chronic  i>eritonitis  associated  with  an 
old  gastric  ulcer.     If  the  investigations  of  Clemens  represent 
complete  knowledge  on  the  subject  we  should  be  able  to  assume 
that  in  these  four  cases  either  tyrosin  orhistid  m  or  both  was 
present  ♦  and  the  fact  of   one  being  a  case  of   carcinoma  their 
presence  would  be  explicable  because  the  products  of  carcinoma 
metabolism  might  well  api>ear  in  this  as  in  other  flmds  of  the 
body       However,  the  reaction  was  not  obtained  in  any  other 
case  of  the  same  kind  nor  in  a  definitely  carcinomatous  effusion. 
The   reaction   was   uniformly  absent  in  subcutaneous  cL-dema 
fluids. 

•  Other  views  as  to  the  nature  of  the  reaction  are  : 
(i)  That  it  is  due  to  phenols  and  amines  (Ehrlich). 
(2)  That  it  is  due  to  paired  sulphur  acids  (Dolgow).  ^  ,.     , 

,    That  it  is  derived  from  breaking-down  leucocytes  (Oeissler,  Sahev). 
4    That   it  will   appear  in   urine  after   taking  opium,   chrysarobin, 
naphthalin,  morphine,  while  it  is  prevented  by  internal  admmistrat.on 

of  tannin.  /\jr~„\ 

(O  That  it  is  due  to  the  chromogi  of  urochrome  (Wetss). 
For  Utcraiurc  and  full  details  see  v.  Noorder,  Handbuck  der  Path.  rf« 

SMfw.  I..  660.     Berlin.  1906. 


56 


STri>IKS  IN    I'tSi  TruK-KLL!DS 


l|t> 


The  Molisch  Reaction ;    the  »-Naphthol  Reaction.— 

The  MolJM  It  icai  tioii  (<)iisi>t-<  in  olitaitiiti^'  a  Molit  (dlotir 
with  an  al(  oholit  xiltitioii  nt  i.-naplitlml  in  the  pii-si-m  i-  ui  ptiio 
siilpliiiiii'    a(  iti.     This   test    was   a|>|>hi-(l   to   the  oii^'inal    tliiiil 


in 


Miii<ls 


il\ 


itti'i 


>f 


t\i 


iiriosjty  in  tiie 

first  placf  isiiiii-  lh«'  icai  Ikhi  ilf|ifii(ls  mi  tlif  piist-iui'  of  (  arho- 
hydiatc  laihi  !t'>^),  and  witli  the  hope  tliat  it  ini^ht  form  a  ifady 
test  loi  till'  piofiK  r  ot  su'  h  in  a  thud. 

It  was  soon  louiid.  howt'Vt-r.  that  there  wen-  striking;  differ- 
vnres  in  the  efte(  t-.  in  ihtfereiit  eases,  so  that  it  has  sinee  tliat 
time  l)een  apjilied  a^  a  routine  pro(  edure.  I  p  to  the  present  it 
is  hard  to  lomiul.ite  any  rules  as  to  (hajjnosis  whieh  mif^ht  l)e 
made  from  it->  presini  !•  or  ahsiiin'.  Tlie  (hfleience  in  the  de^^ree 
of  rea(  tion  is  perhaps  the  most  striking;,  hut  at  the  same  time  it 
must  l)e  admitted  tliat  a  violet  colour  is  never  obtained.  The 
rem  tion  whii  h  one  does  ohtaiu  is  the  formation  of  a  red  rin^  or 
a  red  stainiu(,'  of  the  at  id. 

A  5-per-(ent.  solution  of  a-naphthol  in  (>5  per  cent,  alcohol 
is  prepared,  and  an  etjual  volume  is  added  to  the  Huid  examined. 
Stronj,'  sulphuric  at  id  is  allowed  to  run  down  the  side  of  the 
test-tube,  and  the  contents  are  now  oscillated  gently.  A  red 
line  will  ajipear  at  the  junction  in  a  well-marked  case,  almost 
instantly  ;  and,  with  oscillation  of  the  heavy  acid,  the  latter 
will  become  uniformly  red  (carmine).  The  results  which  have 
been  obtained  are  shown  in  Table  VH. 

From  this  table  it  is  evident  that  as  a  rule  pleural  fluids 
give  a  much  more  marked  reaction  than  do  peritoneal  fluids, 
and  that  in  cases  of  "  idiopathic  "  effusion  the  colour-reaction 
is  very  decided.  On  the  other  hand,  peritoneal  fluids,  esjiecially 
those  dependent  on  back-pressure  (mechanical  effusion),  show  a 
very  scanty  reaction. 

The  difference  in  the  tlegree  of  reaction  dejwnds,  presumably, 
on  difference  in  constitution  of  the  proteid  or  on  difference  of 
substitution  products.  The  presence  of  reducing  substance  in 
the  proteid  of  many  jiuncture-fluids  (some  form  of  carbohydrate 
radicle)  has  been  specially  remarked  on  by  Landolf  of  Buenos 
Ay  res. 

The  absence  of  the  reaction  in  such  a  peritoneal  fluid  as  is 
derived  from  a  case  of  jiolyorriiomenitis  is  suggestive,  lor  the 
fluid  from  such  a  case  has  very  marked  differences  from  any 


THE  CIIIMI*  AL    I  XAMINATION    oF    I'UNfTL'KK-KLLIDS      57 

.,thiT  jmncture-nuia  :  it  is  dear,  or  slightly  opalfsct-nt.  (luitc 
watiMy.  ami  contains  only  a  trat  e  of  ^-lohulin  an<l  ,  ompaiativi-ly 
tiw  t  iUular  dcnu'nls. 


FABLK    VII 
Tii»   <i.NaI"hthol  HrAMioN  or  I'lN.  tuk»-Fi  i  ii.s 


Abunl. 


I  i 


Slight. 


Diitinct. 


Utcidtil 


Very 
Decided. 


Piri.urdial  Fluid  '  Pcritnnral    Peritoneal    rUur^lFlmJ  PUur„IFiin,i  '"'"""'' 


Siiliiillaiuoii^-  Hu' I  •" 
(Kileina  (Car-  Cardial- 
diac)  i«)«--     in 

I'.ritoneal  Klui'l:  Tubcr- 
I'oiyorrho-  rulous 
meniti^i.  Car-  PiTito- 
diai-  Disease  nitis 

TulKTiular  Peri- Cirrhosis 
tonitii  o!  I.ivtr 

Hydatid  Cyst         I'anircatic 
Cyst 


Khiid  in 
Cardiac 
case  in 
t  irrluwis 
M  11  1  t  i  - 
lobti  lar 
Cirrhosis 
,.f  I.iycr 


(Siiii|>le  In- 
tiaminationi 


(1   u  h  c  r  -    Effmx'o" 

ciil.MiM  Uliiticr- 

C  11  I  o  u  s 

cases  (. 

I'e  r  i  to  ■ 

neal    F.f- 

HydatidCysl    lusum  in 

m  o  n  o  - 

lobnl ar 

cirrhosis, 

;  Chronic 

i  Perito- 

nitis 

(simple). 


Ehrlich's  Glucosamine  Test.— As  in  the  case  of  the  Molisch 
reaction,  this  test  has  been  applied  to  a  considerable  number  of 
fluids,  and  similar  marked  variations  in  degree  of  reaction 
obtained.  The  most  striking  point  seen  on  comparing  Table  VII 
with  Table  VIll  is  that  the  latter  shows  mainly  jwritoneal 
fluids  in  the  marked  jwsitive  cases,  while  in  the  former  the  pleural 
fluids  gave  the  more  decided  reaction. 

The  test  is  performed  thus.  To  a  small  jwrtion  of  fluid 
an  equal  quantity  of  a  5-per-cent.  solution  of  /)-dimethylamino- 
benzaldehyde  in  lo  per  cent,  sulphuric  acitl  is  added,  and  strong 
sulphuric  acid  is  run  down  the  sloping  test-tube.  A  deep  violet 
colour,  varying  in  intensity,  will  appear  at  the  line  of  junction, 
and  gentle  oscillation  of  the  acid  will  induce  a  very  intense 
coloration  in  a  positive  case. 

The  results  of  these  exi)eriments  are  shown  in  Table  \'III, 
and  the  differences  in  the  reaction  must  find  some  e.xplanation. 

The  e.xplanation  of  the  test  itself  has  been  the  subject  of 
nmdi  controversy,  and  the  present  opinion  -^eems  tn  be  that  it 
is  the  tryptophane  radicle  which  is  the  cause  of  the  colour  le- 


58 


STUDIES   IN    I'UN'CTU RE-FLUIDS 


art  ion.  Tin-  test  is  called  by  its  name  because  glucosamine  will 
give  the  reaction,  as  well  as  other  osamines.  Neubauer  con- 
sidered that  uroliilinogen  would  give  the  reaction,  but  it  is  not 
generally  accepted  that  this  is  the  ex])ianation  of  the  test  when 
applied  to  proteids  in  general.  I'ap|)enheim  regards  it  as  settled 
that  this  reaction  is  a  pyrrhol  reaction,  though  no  confirmation 
of  this  can  he  found  in  the  literature  available,  although  if  the 
reaction  be  looked  on  as  a  tryptophane  reaction,  the  two  views 
are  readily  reco'iciled,  for  l)oth  tryj)tophane  and  pyrrhol  contain 
the  iniido-group  in  the  same  position  ;  indeed,  Holland's  formula 
lor  tryptophane  contains  jiyrrhol  : 


CH, 

Ml, 

HC CH 

toon 

HC          CH 
NH 

T.    _)toi)liaiie  (Holland), 

The  thickened  letters  rei)resent  the  pyrrhol  group. 

The  (juestion  of  pyrrhol  will  again  come  up  in  discussing  the 
ferments  in  leucocytes. 

If  we  look  upon  the  reaction  as  indicating  the  presence  of 
try|)tophane  in  the  fluids  uniler  question,  we  .shall  be  able  to 
obtain  a  more  tangible  idea  of  the  significance  of  the  test  as 
api>hed  to  pi;ncture-ffuids,  and  the  intensity  of  colour  will 
])resumably  depend  on  the  amount  of  tryptophane  *  present. 

*  I'rvplupliaiH'  (ii  'ol.Tininopropionic  acul)  is  to  some  extent  an  index 
i>t  the  amount  ol  de  .  iction  of  proteids  that  is  Roing  on.  The  substance 
hears  some  relation  to  nulanins.  It  exists  m  three  optical  forms  a  l.evo- 
rotatorv.  a  dextrorotatory  and  a  r.ieeniic.  The  follouinR  tests  may  be 
enipldved  lor  its  detittion  : 

(1)    The  ulyoxyhe  test  (see  below). 

(i)  Bromine  water  in  acetic  acid  nives  a  rose-red  or  violet  colour 
(mixed  mono-  and  ili-bronude  ol  tryptoi)liane  according  to  Leveiie  and 
Koiiiller;.  which  i,m  be  taken  up  by  ann  I  alcohol. 

I})  I'yrrhol  le.tction.  A  match-chip  jiut  in  strong  IICI,  and  then  into 
the  sohition.  turns  cherry  red. 

(4)   /i-diniethvlaniiniibenzaldi  hyde    ti.st. 

It  IS  soluble  in  cold,  readily  in  hot.  water,  but  only  slightly  soluble 
in  .di.--()liiti'    dcohol. 

To  sei>ar.i,.-  it  Irmii  leiu  in  an<l  l\r.in,  I.ixene  precipitates  the  liltrate 
ot  Table  A  with  I'liosphrjtungstic  atid  (four  parts  to  one  of  water),  and 
the  liltrate  therelroni  contains  the  substance  in  question. 


THE   CHEMICAL   EXAMINATION   OF    PUNCTURE-KLUIDS      59 


TABLE   Vm 
Tryptophane  in  Puncture-Kluids 


Ab«cnt. 


Faint. 


Distinct.  Very  Diitincl. 


Extremely 
Decided. 


Simple  Intlam-    Simple    Et^i-    Simple    Effu- 
mation  sion  s>on 

Simple  Inllam-    Adherent  Empyema 

mation  Pericardium, 

etc. 

Empyema 


Non  -  tuber-  I  Simple  Inflam- 
ciilous  EtTu-  ;      matory 
sion  Effusion 

(2  cases)      I      (3  cases) 
Tuberculous    ;  .• 

Pleurisy 
Simple   EtTu-  j 
sion 


Pericardial 
Fluid 


P. 


Cardiac  Back- 
pressure 

Kenal 

Cardiac  Back- 
pressure 


Cardiac  Back-  Cirrhosis     of 
prissurc  Liver 

(2  cases)        Polyorrho- 

Tuberculosis  menitis 

(2  cases) 

Atrophic  Cir-  i 
rhosis  of ' 
Liver    (2)     ; 

'  Monolobular    ! 
Cir^hosi^.      j 

Carcinoma-  i 
tosis  I 

Renal 

Adherent  Peri- 
cardium, etc. 


of 


Cirrhosis 
Liver 

Tuberculous 
Peritonitis 

Tuberculous 
Piritonitis 
(deep  crim- 
son colour) 


Back-pressure 
(cardiac) 
(2  cases) 

Monolobular 
Cirrhosis 

Chronic  In- 
flammation- 
(Non-tubcr- 
culous) 

Tuberculous 
Peritonitis 


Unilocular 
Ovarian  Cyst 


(  Pancreatic     Ovarian  Cyst     Hydatic  1 

Cysts    Ovarian  Pancreatic  (crimson      j 

(Hydatid  f"^'"""-)  ' 

The  fact  that  the  Aclanikiewitz  reaction  *  depends  on  the 
presence  of  tryptophane  will  also  serve  as  an  in<lication  of  the 
presence  of  this  body  in  puncture-fluids.  In  the  cases  which  I 
have  examined,  the  ti-^t  has,  however,  been  seldom  applied,  and 
only  in  the  Table  D  section  of  analysis  (p.  3<')-  The  results  are. 
however,  incorporated  in  the  above  table  (VTII.). 

Pigments.-  The  colour  of  puncture-fluids  is  not  v.f  very  much 
interest.  The  presence  of  blood  will  be  revealed  in  the  ordinary 
way  and  the  presence  of  bile  (which  can  enter  in  cases  of  jaundice, 
or  from  perforation  of  the  bile  passages)  is  easily  matle  out.t 

»  Adamkuw.tz  r.act.on,  Glyoxylic  ac.l  (see  p.  .|8)  is  ad.led  to  the 
solution  to  iH-  teste.1,  ami  stronR  sulphuric  acul  is  ackk-<l.     A  bluc-violet 

colour  results.  ,  , 

t   Nakayamas  ,no<lification  of  Hupperfs  h.le  pi«mcnt  test  is  a  useful 

one,  and  but  little  known  and  use.l.      The  fluid  to  I.e  teste.l  is  mix«l  w.th 


Oo 


STLr»IKS   IN    I'lNCTLKK-KLLins 


The  usual  coloiu'  nt  ittusions  is  due  to  a  lipochrome  which 
can  be  cxtractoil  witli  auivl  alcohol  and  has  a  characteristic 


qiectruui. 


In 


ot   hviinemia,  the  suinutaneous  Huiil  will 


i)e  reuKirkably  pale,  owiii;,'  to  the  dilution  oi  the  Huitl. 

Salkowski's  method  ot  extracting  the  colcmriny  matter  con- 
sists in  collecting;  the  deposit  alter  a'idihcation  of  the  fluid  with 
acetic  a(  id,  and  purilyiuf,'  it  hy  successi\e  solution  ami  reprecipita- 
tion,  and  dissolving;  in  absolute  alcohol.  The  residue  from  this 
is  dissolved  in  chloroform,  and  the  solution  examined  by  the 
spectroscope.  The  addition  of  nitric  acid  to  the  chloroform 
solution  results  in  a  tiansient  blue  coloration. 

The  sja'ctruin  >liows  partial  aiisorption  of  the  rif^ht  half  of  the 
spectrum,  and  a  dark  b.ind  at  F  and  a  paler  one  between  F 
and  (i. 

Gases.  Free  leases  may  ok  ur  in  i)uncture-fluids  from  the 
rupture  of  hollow  viscera  or  from  the  perforation  of  a  j)ulmonary 
<a\ity.     In  rare  (.ases  the  gas  is  derived  from  bacterial  growth. 

The  intrinsi<-  gases  of  the  various  fluids  are  mainly  carbon 
dioxide  with  traces  of  nitrogen.  The  details  which  are 
available  are  mentioned  in  Se:tion  III  under  the  appropriate 
headings. 

The  ( liief  inteiot  in  this  subject  lies  in  the  influence  which 
carbon  dioxide  has  on  the  i>roi)ortion  of  electrolytes. 

The  Inorganic  Constituents  of  Puncture-Fluids.— 
The  most  important  inorganic  constituent  which  we  have  to  deal 
with  is  of  course  sodium  chloride.  The  presence  of  carbonates, 
sulphates,  j)hosi)hates.  is  of  less  importance,  and  is  conveniently 
considered  under  the  one  heading  of  "  .\chlorides "  (see 
Section  II.). 

The  subject  is  more  fully  discussed  in  connection  with  the 
theoretical  consideiation>  on  electro-conductivity  and  later, 
again,  m  Section  I  \'.  We  have  already  iliscussed  the  risk  of  error 
likely  to  arise  from  adsorption  ip.  17)  and  shown  that, at  anyrate 
in  fluids  containing  only  a  small  .iiiu)unt  of  albumen,  the  volu- 
metric methoil  ot  analy>is  is  accurate  enough.  In  the  case  of 
an  iiiual  (iiianlity  ol  lo-pir-ctiit  I. ,11111111  i]il'\hic.  Aftir  .1  short  ccntri- 
fusalisation  tlic  cli-ar  tlniil  is  iKtaiUid.  aiiil  lo  thi'  iishIik'  .{-inch  in  a 
tist-fubo  ol  till'  lollowinu  nuxmrL-  is  addrii  :  1  [ni-  ..int.  lunuiiK  HCl  in 
>1t  jht  ci'iit.  alcohol,  with  Icrric  cliloruli'  aiklid  to  tlu'  acid  in  the  proportion 
ol  4  ]HT  cent.  .MtiT  inixiiiK,  tlio  tliiul  is  hoilod  ami  the  supernatant  ttiiid 
will  turn  mitii  or  lihu-j;rfin,  tiirnini;  \  iok-t  or  n-d  on  adiliii!;  nitric  acid. 


THE  CHEMICAL   EXAMINATION    OK    I'UNCTURE-FLUIDS     6l 


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62 


STUDIES   IN   PUNCTURF.-FLUIDS 


cxud.ites  we  have  to  logai'  the  quantity  of  :  hlondes  estimated 
as  those  whicli  are  "  unattarhed.  "  A  parallel  i-timation  by  in- 
cineration would  he  ot  interest  in  deciding  how  nuuh  combined 
<  hloride  there  was  present. 

The  aceompanyinf,'  table  of  the  amount  of  ehlorides  present 
in  various  fluids  is  of  <  <)nsiderai)le  interest,  inasmuch  as  it  shows 
strikinf^difieremes  in  chloride-(ontent  in  different  classes  of  fluid. 
Thus,  in  the  jileural  series  there  is  a  hij^h  percentage  of  chlorides  in 
back-i)ressure  cases,  and  the  same  is  the  case  with  renal  effusions 
into  the  jieritoneal  cavity.  The  subcutaneous  fluids  in  cases 
of  renal  disease  also  often  show  a  relatively  high  chloride-content. 

The  methods  of  analysing  chlorides. 

I.  Volumetric. 

The  volumetric  method  which  has  been  adopted  in  the 
studies  recorded  in  this  work  is  that  of  Salkowski's  modification 
of  V'olhard's  methoil. 

A  solution  of  2(yoj^  gnis.  per  litre  of  silver  nitrate  is  needed, 
and  lo  cc.  of  this  are  i)laced  in  a  flask  graduated  to  loo  cc.  ; 
4cc.  pure  concentrated  nitric  acid  are  added,  and  distilled  water  is 
used  to  fill  up  to  the  mark.  The  mixture  is  poured  into  an  8-oz. 
flask,  and  5  cc.  of  a  saturated  watery  solution  of  double  sulphate  of 
iron  and  ammonia  adtlcd.  A  solution  containing  about  8  gms. 
of  ammonium  sulphocyanide  is  now  run  in  from  a  burette  until 
the  red  colour  i>roduced  by  interaction  with  the  double  salt 
has  become  permanent.  From  this  reading  it  is  easy  to  find 
out  how  much  water  is  to  be  added  to  the  sulphocyanide  solution 
to  make  25  cc.  of  it  correspond  to  10  cc.  of  silver  nitrate.  It  is  well 
to  test  that  this  is  so  before  using  it  for  actual  analyses. 

The  de-albumenised  solution  is  now  useil,  ic  cc.  being  put 
into  the  graduated  flask,  .]occ.  (about)  of  distilled  water,  4CC.  of 
nitric  acid  and  15  cc.  of  the  silver  nitrate.  The  contents  are  made 
up  to  100  cc.  with  water.  After  thorough  shaking,  the  fluiil  is 
iiltercil  through  a  thick  filter-paper  (Scheicher  and  Scliiill, 
No.  5y8)  until  the  8o-cc.  mark  in  a  perfectly  clean  and  dry 
loo-cc.  moiisure  has  been  reached.  This  quantity  is  then 
poured  into  the  8-o7..  flask  ami  5  cc.  of  the  saturated  solution  of 
double  salt  is  added. 

Titration  is  then  carried  out  with  the  suli)hocyanidc  as  with 
the  control,  and  the  reading  on  the  burette  is  noted. 

The  15  cc.  of  silver  nitrate  will  be  found  more  than  sufficient 


THE  CHKMICAL   EXAMINATION   OF   PUNCTURE-KLUIDS      63 

to  precipitate  aU  the  chlorides  present  in  these  fluids,  and  the 
ammonium  sulphocyanide  measures  the  excess  of  silver  solution. 
The  formula — 

Parts  NaCl  pro  millc  ^--  (37"5  -o'^  K)  04 
Kives  the  number  of  grammes  of  chloride  per  litre.     K  represents 
number  of  cubic  centimetres  of  sulphocyanide  used. 

Since  10  cc.  silver  corresjiond  to  25  cc.  of  sulphocyanide, 
15  re.  corresi>ond  to  37.V  But  only  80  cc.  (08  per  cent  of 
original  fluid)  have  been  titrated,  hence  only  8  of  the  reading 
is  really  required  in  order  to  represent  the  original  filtrate 
The  last  figure  in  the  formula  is  due  to  each  centimetre  of 
AgNOa  representing  001  gm.  XaCl,  so  that  each  centimetre  of 
sulphocyanide  represents  04  gm.  NaCl. 

To  save  mathematics,  a  "  ready  reckoner  "  is  given  m  the 

appendix. 

A  practical  hint  may  be  used  in  these  volumetric  procedures. 
The  difficulty  of  reading  accurately  to  a  tenth  of  a  cubic  centi- 
metre on  the  ordinary  burette  is  got  over  by  the  foUowing  simple 
procedure  which  occurred  to  me  :  A  strip  of  white  paper  is  cut 
sufficientlv  narrow  to  prevent  it  wrapping  right  round  the 
burette.  'Oown  the  centre  of  this  strip  is  ruled  a  clear  thick 
l^lack  line.  The  strip  is  now  attacheil  with  elastic  bands  to  the 
burette,  so  that  the  Figures  are  foremost  (Fig.  2). 

The  upper  limit  of  the  fluid  causes  a 
break  in  the  line  as  seen  through  it, 
which  enables  a  very  exact  reading  to 
be  taken  at  any  level  in  the  burette. 
With  suitable  care  the  slips  will  last  a 
very  long  time. 

2.  The  other  methods  depend  on 
removal  of  proteitl,  thus  : 

(1)  10  cc.  fluid  are  treated  with  20  cc. 
saturated  pure  ammonium  sulphate, 
and  the  mixture  heated  in  a  closeil 
flask  on  the  water-bath. 

(2)  10  cc.  of  fluid  are  diluted  with  90  cc.  of  distilled  water  and 
placed  in  a  flask  closed  with  a  slitted  cork.  Boil,  add  a  few  drops 
acetic  acid  till  the  albumen  separates  out  in  big  flakes, 

(j)  Dry  the  fluid,  and  heat  to  dryness.    Extract  the  ash  with 


I-U-. 


64 


STUDIlN    IN    liN(  Tl'KK-lI.l  IKS 


ph(i>pliai 
mtwt't  iff 


Ixtilin^'  small  iiortions  ol  watii.  and  boil  each  extraction.     Then 
(lilut.    to  70  (1.  with  watir.  and  tiltrr.     The  objections  arc  that 

suiphatcs,  and  i  art  onatos  intcrtfrc,  and  it  the  heat 

00  i4irat  the  chlorides  may  volatilise. 

.  tluit!  are  treated  with  e.xccss  of  alcoholic  tannin, 

hi  nd  filtered. 

!i  (I  -     (  ases  the  (  hlorine  is  ultimately  estimated 

iiti  ,.  alh   V         -liver  nitrate  and  ammonium  sulphocyanidc 

m  til     vay  des(  iU"il. 

THE    FERMENTS 

Ii  ili(  (  ase  ot  cii  tain  ])ii;icture-fluids  the  presence  or  absence 
of  di  .icteristic  ferments  serves  as  a  valuable  aid  to  diagnosis. 
The  tiuid  contained  in  pancre.itic  cysts  affords  the  best  example 
ol  thi>  tilth,  since  the  i)resen'  ••  of  trypsin  or  of  lii)olytic  ferment, 
or  of  liotl  is  almost  consta-'  .\  tyi)e  of  case,  auain,  in  which  the 
di'tectioii  of  '-rments  wo'i        e  of  great  value  is  illustrated  by 


the  follow  tig  :  a  marked  swt    jig  appeared  in  the  1 
ii'gion  attir  ;in  operation  f(     colotoiiiy.  and    vas 
a  fluid      'ilection      ■(     ibly  purulent,  for  th-  te 
igh.      .'.     e:;ploi      iry  puncture  produced       t^ 
ni  1  a  ci   i-idera    le  quantity  of  ix'j>sin,  ami 
i(j  be  !f)rii.    '  hy  an  enormously  dilated  ston 
The  presence  of  ferments  in  a  fluid  not  < 
nosis  to  be  establislied  in  certain  cases    but  n 
as  a  routine  procedure,  with  a  view  tn  dt  tor' 
of  fluid  (exudation,  transudation,  01   (\ 


'  hypogastric 

)ught  to  lie 

erature  was 

vliich  con- 

:  ing  proved 


iiiri 
nin: 
one 


blei  a   Uag- 

>->  l)e  stUiiied 

vhicb    iass 

ex]      t   to 

find  a  given  ferment,  and  in  which  on<  .  ex  to  no 

ferment.  The  universal  absence  of  fer;  s  of  inv  ke  1  a 
]>uncture-f'uid  would  enable  one  to  exciuae  cer^  iir;  saHj^noses, 
Apart  from  this,  however,  the  |)resence  of  these  Ikk!"  or  the 
evidence  of  their  action,  has  an  important  bearing  o  1.  e  pro- 
cesses of  autolysis  which  occur  in  body-fluids  ;  and  autolysis  is 
a  factor  that  has  to  be  borne  in  mind  in  interpreting  the  results 
obtained  by  this  section  of  the  chemical  analysis. 

It  may  be  said  that  the  two  main  peculiarities  of  ferments 
are  that  they  are  very  sjK'cific  in  their  action,  and  that  they  are 
intimately  dependent  for  theii  action  upon  the  nature  of  the 
substrate.  The  s}H>ciftcity  is  shown  by  the  fact  that  while  H  + 
will  produce  a  great  variety  of  chemical  changes  analogous  to 


THE   CHEMICAL   EXAMINATION   OF   PUNCTURE-KLUIPS      6$ 


ferment  action,  a  proteolytic  ferment,  for  instance,  will  not  act 
on  starch  or  fat,  in  spite  of  each  of  these  Ixidies  nndergoing 
a  hydrolytic  chanKe  wh-'n  fermented.  The  second  |X)int  is 
exemplified  by  the  discovery  made  by  E.  Fischer,  that  certain 
ferments  dejK'nd  for  their  action  on  the  stereo-isomensm  of  the 
substrate  in  which  the  ferment  acts. 

Si»eakinR  broadly,  then,  we  may  say  that  ferment  action 
consists  in  a  preliminary  anchorin,:;,  of  molecules  oi  the  ferment  to 
s|Kcitic  grou|)s  in  the  substrate  (phase  i).  followed  by  a  catalytic 
iecmnposition  of  the  same  (phase  2).  This  catalytic  decom- 
jKJsition  continues  up  to  a  certain  {Hjint  and  no  further  ;  for 
eventually  a  state  of  equilibriiun  is  reached  which  does  not 
allow  any  further  change  except  a  reverse  change  (reversible 
reaction).*  The  catalytic  agent,  the  "  ferment,"  simply  alters 
the  rate  at  which  the  catalytic  decomjiosition  occurs,  so  that  in 
order  to  understand  the  practical  apj)lication  of  the  theories 
of  ferment  action  it  is  necessary  to  refer  to  the  laws  l^earing  on 
velocity  of  reaction. 

If  the  velocity  of  reaction  v  lx;tween  two  substa-  :es  of  con- 
centration C,  and  C,,  be  represented  by 

V  --=  k  CXi> 
where  k  is  the  velocity  when  the  concentration  of  a  and  of  b  is 
unity,  the  catalysis  or  ferment  action  would  simply  consist  in 
altering  k.     But  as  the  process  involves  the  production  of  two 
new  bodies,  c  and  d.  in  increasing  concentration, 

I'l  will  =  Ai,C,C , 

and  7'  —  !'|  =  A-C.C,,  —  ^iC.C,    until    the  diminution  of   QCb  is 
counterbalanced  by  the  increase  C,C , 

,    then  comes  to  =  ,.  ,.  • 

The   increase  or  decrease  of  C^Ca  over  C.Ci,  must   therefore 

vary  with  ,  ,  and  -Incomes  a  constant    K,   characteristic  for 

the  particular  ferment. 

It  is  well  known  that  such  a  metal  as  "  colloidal  platinum  "  f 
exerts   a   catalytic   action   which    bears   great   resemblance    to 

*  This  wouUl  in  actual  l.ut  In-  a  simultaneous  process, 
t   I'ropartd    troin   tin-   metal   liy    estahlisliiiig    an   electric   arc   between 
platinum  electrodes  under  water. 


66 


sTLnii^  IN  ruM  irui;-i  i.riiis 


tcniiriii  aitioii.  At  tii>t  >ik1iI  tliiic  is  a  maikcd  tliffrrfiic 
iHtwicii  till-  action  oi  (olloni.il  i)!atini!iii  aii'l  an  oifjanisfi 
tfrnu'nt.*  iH'iausf  a  stihstanc.'  actol  on  hv  the  toinior  iH-comis 
.k'coni|M)Sf<l  till  no  more  uinains,  ami  wlun  actfd  on  l>y  the 
fornunt  tlu'  i)ro(i>-  onlv  contiiuir^  np  to  a  certain  point,  beyonil 
wlncli  it  is  not  jio-^-ihlc  to  proufd.  It  is.  however,  now  estah- 
lislifd  tliat  tlicic  IS  no  cssintial  distinction  Ix'twoen  the  two 
scries  ot  processes,  tor  it  the  meihiim  in  which  the  organised  fer- 
ment is  acting  Ix-  ihhited.  tlie  reaction  will  again  coinnience, 
l)ecaiise  the  concentration  ot  the  products  of  action  i>  diminished 
by  the  dilution.  The  state  ot  equilihrium  which  was  reached 
was  only  a  laKe  eiiuilibriuin. 

The  law  of  mass  action  states  that  the  chemical  action  is 
])ro|K)rtional  to  the  active  mass  of  the  liodies  which  enter  into 
the  reaction,  i.e.  is  i)roportional  to  their  concentration.  This 
law  holds  gcKKl  in  the  casi-  of  ferment  action  also. 

Whether  this  statement  is  absolutely  correct  or  not  has  Ix'en 
dispute<l  tiy  I.ovatt  Evans,  who  >tatcs  that  the  velocity  of  cata- 
lysis shows  three  periods:  (i)  A  rectilinear  jR-riod.  where  the 
masses  of  the  substrate  con\erted  in  equal  intervals  of  time  are 
ai)pro.\imately  e(iual.  The  values  of  the  c()n>tant  k  in  the 
tormula  given  below  steadily  increase  during  the  earlier  phases 
ot  the  reaction,  (i)  A  lo'^arithmic  ]H.'riotl.  At  this  stage  the 
law  of  mass  action  is  followed.  The  values  for  k  are  constant. 
This  period  is  best  seen  when  the  substrate  used  is  in  very  ililute 
solution,   and    the   amount    of   enzyme   is   very   small,     (j)  An 


Tin  cliitl  points  ot  companion  aro  : 


Ciiiioidal  riaunum. 


Kermtnts. 


ku\ 


Ihe  rca<tii>n  takes  plati    acioriling  to 
tlic  IVrrmilii 

,h 

Mic  vtloiity  of  rciction  imrcasis  to  a 
ma.xiimiin  on  addiiif;  molt- Oil    ions. 
(  I  1011  ilimiiii>lie-.  the  velocity. 
K.Sd,  accili rales  ttur  velocity, 
there  is  a  tempi  ratine  optinuint. 
II. S  anil  HC  N  act  as  antilirrnenis. 
lliere  is  no  limit  to  llie  reai  tioii. 


riie  formula  is 


Ditto. 


'■(■  ■ .;) 


Ditto. 

Ditto. 

Ditto. 

Ihtto. 

The  action  ceases  when  the  proiincis 
of  catalysis  reacli  a  certain  con- 
centration. 


TIIF   CHEMKAL   EXAMINATION    OK    PUNCTURK-KLUIDS      67 


euie*ittr*ti»» 


inlmMnrUhmu  ihiuxI.  .lue  to  inoditication  .)(  the  logarithmic 
rours.-  ot  the  reaction  with  the  progressive  destruction  of  the 
,  atalase  The  k  vahies  now  tall.  We  >ee.  then,  that  though  the 
net  result  contonns  to  the  law  of  nuiss  action,  it  may  be  that  the 
details  show  .letinite  fluctuations  ami  deviations  therefrom. 

W'.-  have  to  deal  with  two  cases  (i)  in  which  there  is  only 
„ne  molecule  involved  in  the  decomixjsition-monomolecular 
reaction.  (2)  in  which  there  are  two  molecules  interacting. 

The  velocity  ot  a  monomolecular  reaction  l)ecomes  progres- 
sively less  iis  the  reaction  proceeds.  This  is  indicated  in  Fig.  3. 
where  the  curve  droiw  rapidly  during  the  first  few  seconds,  and 
then  falls  more  gradually  until 
at  last  it  comes  to  lie  almost 
parallel  to  the  base  line.  Ex- 
pressed mathematically  we 
have  : 

_''''  ^k(A-xi, 
<lt 

which  means  that  the  velocity 
of  reaction  with  which  as  small 
an  amount,  .v,  as  you  phase  is 

transformed  during  as  small  an  interval  of  time,  t,  as  you  please 
is  proiwrtional  to  the  original  concentration,  A,  of  reacting 
molecules,  minus  the  amount  of  substance  transformed  during 
that  time  (A  -  x),  k  Ining  a  constant  deix-nding  on  the  nature 
of  the  reacting  system.     When  integrated,  the  formula  becomes : 

k    =      In 

t       .\  —  \ 

where  t  is  the  duration  of   the  reaction  in  seconds.     Ostwald 

gives  a  table  which  enables  log  ^^37^  to  be  reail  off  without 

luither  calculation.* 

The  bimolecular  reaction,  where  two  molecules  are  supposed 
to  be  interacting,  is  frequently  met  with  in  ferment  processes. 
Thi..   type  of  reaction  has  really  been  descriK'd   on   page  ()5, 

C  C 
where  it  is  stated  that  K  =  p-^'-     "  "  ''^'  ^^*^  concentration 

of  the   first   substance,  and  h  that  of   the  substance  acted  on. 

•  See  also  Stction  II..  1,'oncentrntion  ot  Hv.lrumii  Ions. 


I 

I      I 


68 


STUDIES  IN    PUNCTURE  ILUIPS 


then,  as  n  becomes  transformed  h  will  disapjiear.  When  the 
system  contains  a  -  v  pam  molecules  of  the  first  Mil>stance, 
it  will  also  contain  h  -  v  f,'ram  molecules  of  the  second.  When 
intef^rated,  we  ha\f  : 


t  VA  -  x'       A  -  x^ 


Specificity  of  Ferment  Action. —It  ha^  been  stated  above 
that  one  of  the  most  striking  characters  jH>ssessed  bv  ferments 
is  that  their  action  is  si)ecific.  The  investigations  which  Jacoby 
has  made  on  ferment  action  have  led  him  to  discijss  whether  all 
ferments  do  possess  this  property.  While  sonu  proteolytic 
ferments  are  intensely  siK'cilic  inasmuch  as  the  synthetic  jxjly- 
jK-ptids  of  Fischer  and  Aberhalden  are  not  acted  on  except  in 
the  case  of  those  which  occur  in  nature,  other  ferments  do  not 
xhibit   this  projxrty. 

Heat-production  in  Enzymatic  Reactions.— Any  reaction 
in  which  heat  is  develojxHl  externally  (whether  measurable  in 
quantity  or  not)  is  called  exothermal,  while  if  heat  i  absorl)ed 
,1  is  called  endothermal.  Passing  up  from  the  al)solute  zero, 
we  come  ujwn  a  succession  of  reactions  where  the  development 
of  heat  becomes  less  and  less  exothermal  until  we  reach  a  jxiint 
at  which  all  the  reactions  are  endothermal.  At  this  stage  of 
the  series  we  come  uix)n  a  condition  in  which  the  >ul)stances 
ordinarily  split  up  by  the  ferment  are  regenerated. 

The  more  nearly  endothermal  the  reaction  the  more  it 
approaches  a  reversible  reaction.  The  relation  between  ferment 
action  and  heat  production  affords  an  explanation  of  the  pro- 
cesses of  al)sorption  in  the  intestine,  for  instance,  where  reversible 
reactions  are  constantly  going  on.  In  a  tabic  given  by  Holx-r, 
it  is  shown  that  the  hydrolytic  fermentations  have  a  low  pro- 
duction of  heat,  while  the  oxidations  have  a  high  one.  Thus, 
maltose,  cane-sugar,  and  lactose  give  a  value  of  j  to  7,  fermenta- 
tion of  dextrose  into  lactic  acid  gives  a  value  147,  while  for  the 
conversion  of  salicylaldehyde  into  salicylic  acid  the  value  is  72-6, 
so  much  greater  is  the  heat  of  reaction. 

The  occurrence  of  endothermal  reactions  has  some  bearing 
on  the  question  of  autolytic  decon^josition. 

The  proiludion  of  heal  by  fci  ment  action  may  provide  a  means 
of  detecting  and  of  estimating  the  amount  of  ferment  present  in 
a  fluid.     Such  a  method  has  Uen  elaborated  by  Tangl  and  his 


THE  CHEMICAL  EXAMINATION   OF   PUNCTURE-FLUIDS     69 

|.u|.ils.  The  chemical  energy  of  the  mixture  to  be  (ermentc.l 
was  determined  both  Nfore  and  after  the  action  of  the  ferment 
1,V  determining  the  dry  substance,  the  a^h,  the  nitrogen,  and  the 
calorimetric  energy.  It  was  thus  estabhshed  that  when  the 
tryi)sin  acts  on  albumen  the  chemical  energy  is  not  turned  mto 
any  other  form.  t)n  the  other  hand,  in  hydrolytic  ferment  action 
th.'  energy  progressively  diminishes  as  digestion  proceeds.  Her- 
/,.g  found  that  oxidising  ferments  are  associated  in  their  action 
with  the  pro^hKiion  of  thermal  energy,  whereas  reductases  show 
,u)  such  change,  and  the  ferments,  acting  on  i^lysaccharoses 
glucosides,  fats,  and  proteids.  only  show  a  small  production  of 
luat  When  heat  is  produced  by  the  action  of  a  ferment  within 
th.   body  this  will  be  a  factor  in  the  maintenance  of  the  Ixxly 

heat. 

The  effect   of   temix>rature  on   the  velocity  of  reaction  is 

given  by  the  following  formula  of  van't  Hoff : 

In*  -  ^,,  +  constant, 
K  1 

where  k  is  the  equilibrium  constant,  and  q  represents  the  heat 
devel  .ped  during  the  reaction,  Dnd  T  is  the  absolute  temperature. 
R  is  a  constant. 

The  bearing  which  all  these  considerations  have  on  the  study 
of  puncture-fluids  is  that  the  progress  of  an  enzymatic  reaction 
in  a  puncture-fluid  can  Ixj  observed  by  their  means.  For  instance 
the  conversion  of  cane-sugar  into  invert-sugar  .an  be  watclu^d 
by  means  of  polarimetry,  and  calculated  by  the  use  of  the  formula 
given,  the  degree  of  rotation  being  proportional  to  the  velocity 
of  reaction.  For  instance,  if  A  be  the  initial  concentration  of 
the  cane-sugar,  A  must  l)e  expressed  in  terms  of  degree  of  rota- 
tion. Let  /  be  60  (duration  of  reaction,  one  hour).  The  change 
of  rotation,  x,  divided  by  A,  can  be  calculated  by  means  of 

A  ., 

Ostwald's   table,   which   gives   the   value   for   log   x^~^-      "' 

however,  the  velocity  be  compared  with  that   of  a  standard 
reaction,  the  calculation  becomes  more  simple  : 


k  -= 


I  total  rotation  possible. 


log. 


total  rotation  —  rotation  at  the  rnd  ol  time  /. 


Further   remarks   about   this   polnrimetric   method  will   \^ 
found  in  Section  II.,  under  "  Ionic  Concentration." 


MICROCOPY    RESOLUTION   TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No   21 


1.0 


I.I 


1.25 


;-  iiiiM 

•"-     13  6 

I-      1^ 

I-       ■■■ 


1.4 


2.5 
2.2 

2.0 
1.8 

1.6 


^     -■APPLIED  IK/MGE     Inc 

'-^S  ,:'^:    *o;     -  0300  -  (^hone 

^^         (?'6)   ^88       ^98^  -  fan 


70 


STUDIES   IN   I'UNCTURE-FLLIDS 


The  Ferments  which  may  be  met  with.— The  following  is 
a  list  of  ferments  according  to  the  classification  by  JoUes  : 

I.   Hyih"!ytir. —  ln>o\nh\r   1io<1k>  ari'   lomiilUd   to  take   up  water  and 
hiconu-  convi-rttil  into  soliililf  hotlif^. 

Duistii^c.  iiWittiisi  .  liiilds,.  tiiluilds,   turn  bK)-.i>  (i.anr->UKar,  malt- 
suf^ar,  niilU->UKar)  into  nionoM>  !■>•  takiUL;  up  water  (=k1ucom', 
li'Vulost). 
Ltpiiii-  or  '-ti'ap-in  <aponilu-^  neutral  lats  (ir.ehulint!  lecithin  ami 

oil>). 
Jimiilsiii  break-,  up  «hico>icle>,  i .;'.  aniyyilalm. 
I  'nasf. 

Protcfilylu  ferments,  includin!'  erep^in.* 
II.   .Ik/.)/}'//!.— Break  up  bcxlies  without  lo-s  of  water,  (.;,'.  zymase.     Tlu^e 
enzymes  are  intracellular  and  l>lay  an  important  part  in  the  iiuta- 
bolic  processes. 
III.   C'>ii!;iihtiiii;.— form  jellies  irrnnet.  tlironilio>e). 
IV.   Oxyctiiscs  accelerate  oxydative  jirocesses  (miaiacum  test)  and  play  an 

important  part  in  the  lile  of  the  tissues,  e.s;.  xanthinoxydase.t 
V.   Cdtaliiseis.  which  decompose  Up,. 
\l.    The  Aiitihriniiil'i. 

METHODS  OF  DETECTING  AND  ESTIMATING  FERMENTS 
ON    rUNCTURE-FLUIDS 

The  fact  that  these  ferments  do  not  all  occur  in  the  different 
puncture-fluids  with  which  we  are  concernetl  renders  it  un- 
necessary to  discuss  the  means  by  which  each  is  identified.  We 
are  only  concerneil  with  diastase,  invertase,  lipase,  proteolytic 
ferments,  oxydase,  catalase,  precipitins,  and  antiferments. 

I.  Diastase.— Ascoli  and  Bonfanti's  method.— Add  2  cc.  of 
the  fluid  to  be  tested  to  100  cc.  rice  starch  (i  per  cent.),  and 
I  cc.  toluol.  Shake,  and  incubate  twenty-four  hours  at  37"  C. 
The  fluid  should  lemain  sterile,  and  i  per  cent,  sodium  chloride 
is  then  added,  and  the  fluid  boileil  in  Soxhlet's  apparatus. 
A  few  drops  of  dilute  acetic  acid  are  added,  and  the  fluid 
again  raised  to  the  boil.  Rapidly  filter,  and  estimate  the  sugar. 
Potato  starch  may  be  used. 

*  Krepsin  acts  on  peptone,  deiitero-alliumose,  .iiid  cluseiu.  coiuertins 
tliem  intolcucin.  tyrosin,  ammonia,  arniinn.  l\^in,  etc.,  but  cannot  act  on 
albumens  of  blooil  and  ascites,  globulins,  or  Heiice-Jones  jiroteid  (Sieber 
and  Schumotl-Simonowski). 

+  Xanthinowdase  is  one  of  the  four  lerinents  which  play  the  chiel  part 
in  nucleiu  metabolism;  (i)  tiiu.'lvlii  fcnnciit.  met  with  in  kidney,  liver, 
antl  muscle;  (i)  uuileusc.  breakmir  up  nucleic  acid  and  liberatiii!;  purin 
l,ases.  met  wiih  in  i!ie  liver  and.  muscles  :  !  -i)  a  il-:<:i.">>'li^ii>S  uiment.  turmn.!; 
aminopurins  into  oxypuriiis  ;  (4)  .\\iiithiii>\\<liise.  whicli  turns  hypoxantl.m 
into  xanthiii.  .imi  this  into  uric  acid  (Schittenholm  and  Schmid). 


Tin-:   (JIIEMICAI.    KXAMINATI..N    OI     IT  NCTU  RK-H-UIDS       "I 

Walthor  cloviso.l  a  .n.thoa  similar  to  that  ..1  Mott  tor  .stim.- 
Narrow  tuhos  are  f.llod  with  starch  pasti-,  and 


tion 


of  ix-i 


)sin. 


the  length  of  •■olunin  after  digestion 


■ad  off  with  a  len- 


Wohlgemuth  (,uite  recently  (i.»c.M  advocates  a  method  .n 
which  the  degree  of  reaction  is  estimate<l  colorimetrically  by  the 
use  of  decinormal  iodine. 

>    Invertase  -This  is  detected  by  the  formation  of  reducing 
.ub^tance  after  incubation  witli  a  5-por-cent.  solution  of  cane- 
sugar,  toluol  having  been  added.     The  glucose  n.ay  be  estima  ed 
V  Lipase.-This  ferment  is  more  abundant  in  exudates  than 

in  transudates.  r     »k,.i 

(a)  The  neutral  fluid  is  treated  with  a  few  drops  of  eth\l 
butvrate  in  a  te.t-tulx-  and  litmus  solution  added.  After  twenty- 
four  hours'  incubation  the  litmus  is  found  red  if  hpase  is  present, 
while  a  control  tube  is  unaltered. 

Titration  with  baryta  would  enable  the  amount  of  ferment 
to  be  calculated,  supposing  that  the  same  length  of  incubation 
were  given  in  every  experiment. 

Robscn  and  Cammulge  pent  out  that  a  trace  of  -l-»"^  -IJ  --[  ^^ 
aclcUa  to  the  rtuul  to  l,e  teste.l  ,n  the  cus.  of  pancreat.c  c>,t  rtuul.  a, 
l.ancnatic  fernunt  alone  will  not  react. 

(b)  Alternative.  Ethyl  butyrate  may  l>e  replaced  by  an 
ethereal  extract  of  olive  oil  containing  sodium  cartonate,  the 
extract  being  allowed  to  evaporate.  The  advantage  of  this  is 
that  one  has  a  ready  means  of  preparing  the  requisite  neutral 
fat   instead  of  having  to  prepare  or  purchase  ethyl  butyrate 

Pepsin  —The  number  of  methods  which  have  lieen  ad%-o- 
cated  for  estimating  the  amount  of  pepsin  in  a  fluid  is  remarkable, 
and  may  be  taken  to  indicate  that  no  one  of  them  is  quite 
satisfactory. 

The  chief  inethoas  may  be  classilied  as  loUow.-,  : 

,  Methods  where  the  anionnt  of  albunun  lelt  untouche.I  .s  notul. 
e.,.  mJasurement  ol  the  column  of  albumen  lett  m  .Metfs  I"'"- 

z.  Methods  where  the  ,.ro.U.rLs  of  .ligesfon  are  ..xam.ned  (estnnat.on 
of  alteration  in  acidity  ;  Volhards  metho<l). 

,,.  Methods  based  on  the  determination  o.  nitrogen  in  ,he  residue  and 
in  the  solution  alter  digestion. 

l.ulLnn  observes    the   tune  occupie.l   in   clarify,n«   an  ;->'  -"•-  ° 
coauuiatea  e,K-alhumrn  in  uhich  hydrnrhloric  acul  i^  present.      He  Kiys 
a    able  which  he  has  prepared  by  takin,  known  strengths  of  pepsin  sohi- 


:y 


STUDIES   IN    rUXCTL'RE-KLUIDS 


lions  (Armours  |h|>mii)  i.iid  oliMTViiii;  tlic  time  ()ctiii>iicl  in  dissolving 
the  ('tjy-nllniimn. 

The  nutlioil  lias  the  t;r<:il  (.lijntion  lli.it  on>-  i-  lulfy/iss  uilhout  lii\  tahU. 

liitin  Milhuls.  Solnis  placrs  j  cc.  ol  a  o- j5-pir-C(nt.  solution  ol  ricin  in 
50  percent.  XaCl  in  each  ol  a  -<  vies  of  test-tiil.es,  and  also  places  o^cc. 
decinornial  hydrochloric  acid  into  each  tube.  Successive  strengths  of  the 
jiepsin  solution  are  added  to  each  mlie  (i  cc.  boiled  fluid  :  o<>cc.  cf  Imilwl 
fluid  +  o- 1  cc.  of  unboiled  Hnid  diluted  too  times  ;  8  cc.  boiled  +  1  cc.  unlKiihM 
•  liliited  fluid  ;  tcc.  iuiileil  + -3  cc.  unboiled  diluted  ;  locc.  unboiled  diliitftl 
fluid  I.  The  corkeil  tuUes  are  incubated  for  three  hours,  and  it  is  then 
noted  in  wliicli  tube  the  lluid  ha>  Income  clarified. 

.\  Hiiul  ol  which  1  cc.  in  a  liundrc.l-lold  dilution  clears  up  the  turbidity 
in  three  hours  is  a  flui<I  containing  ino  pe])sin  units. 

1  his  method  is  most  useful,  of  course,  in  the  analysis  of  ordinary  gastric 
contents.  It  may  be  doubted  whether  there  is  any  gain  in  estimating 
the  amount  of  jh  p^in  in  a  puncture-fluid  from  a  cavitv  which  might  contain 
pepsin. 

.\  discussion  011  tliis  method  occurred  at  the  Berliner  .Med.  C.e.sell.schaft 
;n  July  of  i.>o;,  Kleniperer  there  advocating  the  nse  of  edestiu  in  place  of 
ricin  (i-per-cent.  solution),  but  Jacoby  and  Fuld  failed  to  see  any  advan- 
tage in  such  a  modihcation.      Keicher  recommends  Jacoby  s  method. 

Iiild's  .Uf/Ai)(/.— This  was  de\ised  in  order  that  the  presence  of  pepsin 
could  be  (leiected  with.in  a  minute. 

To  .:cc  of  a  i-ixr-cent.  solution  of  cJestiii  in  ,,?,-,  normal  HCl  is  ad<led 
enough  of  the  hundred-fold  dilution  of  flui<l  to  be  tested  as  shall  cause  a 
precipitate,  .\fter  incubation,  ammonia  is  poured  on  till  a  distinct  white 
ring  appears.  I  f  the  ring  does  not  appear  it  means  that  more  than  four-fifths 
of  the  albumen  has  been  digestetl.  The  temperature  of  incubation  and  the 
time  of  digestion  may  be  arranged  as  desired  by  adjusting  the  strengths 
of  the  solutions.     The  test  is  described  as  exceedingly  delicate. 

Hlum  and  Fuld  describe  a  method  of  estimating  pep.sin  by  estimating 
the  leiiiiet  {ihymosin),  which  they  assert  runs  parallel  with  pepsin.  For 
this  purjiose  a  special  jireparation  of  dried  milk  is  used.  It  is  not,  however, 
necessary  to  refer  more  closely  to  this  method,  as  it  is  applicable  only  to 
gastric  contents.* 

-\n  ingenious  method  of  estimating  the  progress  of  proteolysis  by  the 
use  of  the  viscosimeter  has  been  utilised  by  Spriggs.  Starting  with  a  given 
proteid  solution,  the  moie  the  proteid  becomes  resolved  into  its  decom- 
position products  the  less  viscous  will  the  lluid  become.  The  diminution 
of  the  viscosity  may  be  used  as  a  measure  of  the  progress  of  digestion, 
.since  the  acMition  of  aci.l  to  a  iroteid  alone  does  not  alter  the  vi.scosity 
for  a  very  con.Mderable  time. 


In  any  cas<\  the  method  is  cumbersome,  as,  to  estimate  the  rennet,  a 
succession  of  tubes  with  different  dilutions  is  used.  Twenty  or  thirty 
tubes  being  necessary,  the  method  cannot  be  described  as  convenient,  nor 
can  It  be  of  ready  application  (an  argument  which  applies  with  equal 
force  to  Brandbergs  nietho.1  of  ■•stiniatin-r  albumen  in  urine).  A  half- 
gross  of  test-tubes  used  for  any  one  estimation  is  to  be  avoided  unless 
there  are  plenty  of  assistants  '. 


THE  Clir.MICAL   EXAMINATION   OF    ILNCTUKK-FLIIDS      73 

The  vc'locty  ol   reaction   was  .Uduccd    by    tlus   lornu.Ia,   ba-r.l  on   a 
niiiiil>iT  of  observations  : 

,  =  _*     |7'(2    )     ,,, 

.vlur.-  lis  the  .legrcr  oi  v,sco>ity,  wlucl.  is  s„ll  capal.K-  ol  further  .linnnu- 
non;  />l  th..  restive  a.  idity  o.  the  pepsin  ;  t  is  the  tune  o.  reaction  in 
s.conds.  and  k  and  ii  are  constants. 

The  onlv  objection  to  the  method  i.  the  elaborate  apparatus  that  i 
idv  ,  atc"l  Of  course  one  could  at  intervals  abstract  a  portion  of  fluid 
t::;':::  a  wUh  the  Hess  instrument  ,see  Section  ..,.  ^-P-^.  ';:/°- 
•„  a  constant  temperature  NVithin,  at  any  rate,  a  decree,  llov.v.r,  this 
luld  l":  Ipt  to  become  tedious,  as  the  instrument  would  have  to  be  cleaned 
out  so  often  durinK  a  short  time. 

;  Estimz^on  of  Trypsin.- The  l^est  methocl  is  that  pub- 
lished by  F.  Volhanl.  The  principle  of  this  method  is  that  U  a 
special  pre,,aration  of .  ..ein.  to  which  hydrochloric  acid  has  beeu 
added,  is  treated  with  ix>psin.  the  acid  caseo.es  formed  cease  to  be 
precipitable  by  sodium  sulphate,  so  that  the  fiuid  is  more  acid  than 
before  When  the  casein  is  exposed  to  trypsin  instead  of  pepsm, 
in  the  presence  of  alkali,  and  after  this  is  acidified  with  a  certain 
•unount  of  hydrochloric  acid,  and  sodium  sulphate  added,  the 
Increase  in  aJidity  is  agam  a  measure  of  the  amount  of  ferment 
action.     In  the  case  of  FP^i"  the  increase  in  acidity  is  equal  to  - 

where  /  =  quantity  of  i^psin,  and  /  =  time  of^igestion. 
In  the  case  of  trypsin,  increase  in  acidity  —  k*.f. 
The  method  is  a  valuable  one,  and  the  procedure  is  as  follows  : 
Preparation  of  the  Casein  Solution.-ioo  grammes  of  finely 
granular  casein  (Chem.  Fabrik,  Rhenania.  Aachen)  is  dissolved 
in  Ii  litres  chloroform  water,  and  80  cc.  of  nNaOH  added.     As 
soon  as  the  casein  has  dissolved  in  the  water-bath  the  fluid  is 
heated  rapidly  to  90X.  to  kill  ferments  and  bacteria    and,  on 
cooling,  the  bulk  is  ma.le  up  to  2  litres,  and  toluol  added.     The 
reagents  must  be  kept  in  Woulff  bottles. 

Solutions  required  : 

Casein  s-olution 

.,/+  NaOH 

H  HCl 

20%  Na,SO, 

Chloroform  water 

*   In  each  case  Ai  is  a  constant. 


STUniKs    IN    I'L'N<TURK-1I.(  IDS 


Pi<()(  KUiKi:.  riiRT  tl.i'-k-  an'  ummI.  t:ic-li  liaving  ;i  joo-cr. 
iiKirk  at  till'  lowti.  and  a  4o()-tc.  mark  at  tlir  iiiipor  I'lul  of  tlic 
luck.  V.M'h  it((i\f^  iiio  cc.  of  ( aM'iii  solution,  and  chloroform 
water  is  addfd  tip  to  the  lowir  mark.  To  No.  i  fiask  add  3  cc. 
nriitraliscd  thud  and  11  cv.  );H('l.  to  anotiier  (No.  i)  add  5  cc. 
neutralised  fluid  alone.  Flask  ]  is  the  control.  Incuhate  at 
40  (".  for  about  eifihteeii  liours.  and  then  add  11  cc.  hHCI  to 
flasks  2  and  j,  shukin,!,'  till  the  precipitate  is  dissolveil.  20  per 
cent,  sodium  sulphate  is  added  up  to  the  4()o-cc.  mark,  shaking 
well.  This  (irecipitales  the  undigested  casein.  Filter  through 
a  dry  hlter.  and  titrate  joo  cc.  with  11  4  soda,  against 
phenolphthalein. 

Tlu'  increase  of  acidity  is  a  measure  of  the  amount  of  ferment. 
The  number  ot  cubic  centimetres  of  soda  needed  to  neutralis-.' 
200  cc.  of  flask  I,  minus  the  numl)er  required  for  flask  3,  gi'.'cs  the 
amount  of  jx'psin.  the  munher  required  for  flask  2,  minus  that 
required  for  flask  3,  gives  the  value  for  tryi)sin.  so  that  the  ratio 
pepsin  trypsin  is  readily  obtained. 

In  spite  of  its  apparent  complexity,  this  })rocess  is  not  at  all 
troublesome  to  carry  out.  and  can  lx>  highly  recommended. 


.\  strus  <il  nio>t  ini|i(irtant  n-scarclics  dtaliny  with  tlu'  estimation  ol 
proteolytic  Itrnn'iit  action  has  licen  made  by  Sonn^in.  He  started  with 
the  assumption  tluit  ;)/  llii'  iiiiiin  prcttolysis  is  a  hydrolysis  with  the  forma- 
tion of  carhoxyl  and  amino  groups  The  other  groups  taking  part  in  the 
decomposition  are  assumed  to  he  netjliKible.  The  amino  groups  can  be 
"  ti.xcd."  as  it  vcre,  by  formol.  and  the  carboxyl  groups  can  then  l:e 
estimated  by  titration  with  11/5  barium  hydro.xide  against  thymol phthale in. 
The  number  of  centimetres  used  multiijlied  by  jS  giyes  the  number  of 
milligrammes  of  nitrogen,  since  the  formation  of  each  carboxyl  corresponds 
to  the  formation  of  an  ammo  group.       The  reaction  is  exemplitied  thus  : 


CTI, 

CH.N!I,  +  HCOIl  +  KOH 

COOII 


CH, 


CH,  N:  CH,  +  H/)  ^  II.O 

COOK 


The  conditions  for  the  reaction  are  (l!  a  suitable  strength  of  formol  :  (2) 
a  suitable  concentration  of  hydrogen  ions;  {>,)  a  suitable  indicator,  which 
shall  be  sensitiee  for  the  particular  degree  ol  concentration  of  hydrogi'ii 
ions;   14)   a  suitable  Noluiueol   Hind,      ll   tlu^e  conditions  be  not   fultilkd 

th--    p-;ir};o:i    will    rry-v~>\ 

The  objections  to  the  method  are  that  it  gives  inexact  results  with  proliu 
anil  tyrosin  and  guani<lin  salts.     Tliymolphthalem  cannot  be  used  if  the 


THE   CIILMICAL   KXAMINATION   OF    PUNCTUkE-l- LUILS      75 

.Icohol  .n  .t  soparat..  out  .n  tlu-  tinwl  tmut.-l  wlur.  ilu-  prot..,!.  ar.  onlv 

"   u'  ,n  alcohol  «.th  .im.cultv.      A  ^uat  ol.,..e.w.n  to  .  u-  -•'""''- 

„  ..  th.r.l  con.htu.n,  s.nc-  one  has  to  mo.hty  one'.  ,mK..lun.  accor.l  n«  .  . 

..  Xlucts  to  lu.  c...>n,ate.l   an.l   acconhn«   to  the  fornunts  .-.np  ov.-.l. 

u.    mf.n-nce   ,n   the   vaUu.   for  .nzynu.   act.on  as  nt.asur.a   bv   lor.uo 

a  on  from  that  as  nuasure.l  bv  pr.c.p.tat.on  w,th  tann.c  ac.l      an.l 

1     U    n^^    .s  v.rv  «roat  .n.h-d.     How.v.r,  wnportant  ,n.provo.n.nt> 

!:';;;';neS,  l.,..  .0'.  cone.,  n.truct.on,  as  to  .ts  us..  n,ay  W  .■xpec... 

to   lollow.  1    »     I  *  1  ,. 

6  Guanase  and  Nuclease. -r he  ferments  may  i.e  .>oiate<i    i.v 

uMHn.lm..  the  preop.tate  result.nK  .ron,  a.l.l.tion  of  ammon.um  sulphate 

"   x":nt  o,  <..  ,H.r  cent.      The  pseu.lo-Klobuhn  so  precp.tate.l  carnes 

H       r„u-nt.  just  as  the  same  l.o<ly  carr-es  lecthm.      I.  th,s  suspens.on  he 

nwUh 'chloroform  for  an  hour  an.l   then  .haly...l  ^^^^;^^^^^ 

water  till  free  of  ammon.a     a   procedure   wh.rh    mvolves  ..to   H  clav  s 

the   nitrate   «,11   be   foun-l   to  be  slightly  coloured    an.l    ,<.   be  .levoul  o. 

'""since  the  ferment  .s  character.sed  by  convert.n«  free  purm  l«ses  .nt,, 
.,,..  acul  the  presence  of  th.s  fernu.nt  can  be  detecte.l  by  ascorta.n.ng  .f 
.niinin  be  converte.l  into  uric  acul  or  no.  ,  ,       ,  ■ 

'  The  Kuanm  .s  .hssolved  ,n  normal  soda,  an.l  the  ch loroforme.l 
nnxt  e  kept  at  bo<lv  heat,  an.l  a,r  at  43  is  P-se.l  through  or  tlm-e 
;,:;;.     The   oxulisingacfon   ts  necessary  tn  order  that  ur.c  acul  may  be 

•'"n'uie  fermentation  is  allowe.l  to  take  place  m  the  absence  of  an  a-r 
current  (S.X  .lays'  .ncvd.at.on  at  if  C.)  xantlun  :  n.ay  be  searched  for  ,n 
order  to  Drove  the  presence  of  the  guanase. 

This  foment  acHon  ,s  a  .lesamuUsation,  wh.lst  the  other  act.on  .s  a 

'"'"•^Itsfmav  be  detected,  acconl.ng  to  AbderhaUlen  an.l  Sclnttenhelm. 
l.v  'the  action  of  (lo  cc.)  the  Huul  on  a-thy,no„ucUc,te  of  soda  (lo  gm. 
ssolved  n°  50  cc  water  at  ,7^  C.  for  several  .lays,  toluol  hav.ng  been 
tide  to  prc-vcnt  decompos.t.on.  The  resulting  medunn  wtll  ha  ye 
S  on  e  flu  d  and  clear,  an.l  .,11  not  set  on  cooUng  .f  nuclease  be  present. 


.  Tannm  metho<l.     .0  cc.  flui.l  are  neutrahsed  wth    K    or  so.  a,  an 
2  cc    normal   sodu.m  acetate,   neutral   to  ..tmus,   are  a.l.led.     Then  a.k 
-.cc.  ot  xo-per-cent.  aqueous  tannut  and  hU  up  to  50  cc  w.th  ..ten    .hake 
V   11       stand  ovennght.      Filter  next  .lay.      I.stimate   the  N    in    23   «. 
^J^\^:^J^^  m..tho...     Multiply   the  result   by  .   .0  obtain  the 
N-content  of  20  cc.  in  milligrammes. 

t  ^' d^t^J^a^l  estimate  xanthin.-The  value  of  this  lies  in  the  adop- 
tion of  the  metho.l  for  estimating  the  amount  of  guanase  present  in  a  fluuL 
Tira  .  men  is  hrst  removed  by  boiling  in  faintly  acid  (acetic)  reaction 
.nc  silver  nitrate  is  a.l.le.l  to  the  hltrate.  The  precipitate  ,s  washe.l  in 
t;; L,  ,; Vthen  warm  hv.rochlonc  acid  is  adde.l.  The  filtrate  is  .Irie. 
'^d  boiled  with  dilute  ammonia  to  remove  the  hydrochloric  acul,  and  kit 
on  ice  overnight.     The  filtrate  contains  xanthin. 


I 


70 


STUDIES   IN    rUXCTURK-KLUinS 


I'liiin    liixlit-.   tail   aKo  In    ^larcluil    Im    a-.  i\  ulciict' ol  tlii'  action  of   tl'is 
Irrniint.* 

TIk'  ii.ilinc  <>1  iiui.li  aM'  li,i>  lucii  llu-  ■.ulijixt  of  imitli  iliscusMon.  Sonn- 
authors  consiil.  r  it  to  lie  the  saim-  a^  trypsin,  Imt  il  trypsin  Ix'  adili'd  to 
mil  lease  the  action  ol  trypsin  will  tci-e.  This  (erment  CKCurs  normally 
in  the  th\tniis,  pancrias,  ami  kidiievs  in  cows. 

7-    Oxydases.  -  Sill  Mr    «i\es    the    characters    possessecl    by    three 
varieties  ot   ox\ilase>. 


HI 


I  in  water 


Solubility   -'   in  neutral  salts 

I   in  alcohol  and  water 
Saltirit:  out 
ElRct  of  hi  at 
Amount  cf  sugar  acted  on  in  two 

days 
Kate  ol  inversion  of  disaccharids 
Kate  of  inversion  of  polysaccharids 


destroyed     easily  destroyed 

slow       I        immediate 
rapid       I         less  rapid 


4. 
destroyed 

80% 

slow 

less  rapid 


Dflcctinii  ,111(1  Estimation  of  Oxydase  (Jolles'  Metlioil). — '05  cc.  of  the 
fluid  to  be  tested  is  nii.xed  with  about  30  cc.  of  oi»  per  cent.  NaCl  in  a 
50  cc.  flask  and  hlled  np  to  the  mark  with  the  saline.  10  cc.  of  this 
mixture  are  treate<l  with  30  cc.  ot  luutial  HjO.  and  incubated  in  the  cold 
incubator  for  twenty-four  hours,  the  time  of  commencement  beiuR  noted. 
.\fter  this,  sulpliuric  acid  is  added  to  stop  the  action,  and  the  time  is  again 
noted.  I'otassiiim  iodide  is  added  drop  by  drop.  Iodine  separates  out, 
and  after  an  hour  the  iodine  is  titrated  with  dccinornial  thiosulphate. 
The  original  strength  of  the  hydrogen  dioxide,  less  the  strength  at  the 
conclusion  of  the  experiment,  sliows  the  amount  decomposed  bvo'oi  cc.  of 
blood.  The  amount  decomposed  by  1  cc.  is  the  "  catalysisfigure."  which 
is  normally   iS  to  30  for  blood. 

.\  similar  method  has  been  used  by  v.  Dalmady  and  v.  Torday,  but  their 
work  is  confined  to  tlie  blood  itself. 

Van  Itallie  has  u.sed  the  method,  with  slight  modifications,  in  order  to 
distinguish  between  the  blood  of  different  animals  by  the  \arying  catalytic 
power. 

Xanthin  oxydase  was  estimated  by  Burian  by  ascertaining  how  much 
uric  acid  was  jirodiiced,  and  the  \  elocity-constant  of  this  action  was  made 
out  to  be  as  of  a  reaction  of  tlie  first  order. 


*  To  test  for  purins. — .\dil  sulphuric  acid  to  the  filtrate  to  remove  free 
nucleic  acid,  and  to  the  liltrate  add  mercury  sulphate,  which  will  throw- 
down  the  purins.  The  pnrin  precipitate  is  soake<l  in  water,  and  HCT  and 
H^S  added  to  remove  the  mercury,  the  H  S  being  removed  by  an  air- 
current.  .\mmoniacal  silver  nitrate  may  now  be  used  to  precipitate  the 
purins.  I'i'ui  r  an>i  wash.  IKai  tlie  ,(iecipil.ile  with  liCi,  iiiler  oil  the 
silver  chloride,  and  add  H_S  and  again  lilter.  The  filtrate  is  evaporated 
and  the  purins  separate  out,  are  puritied,  dried,  and  weighed. 


TIIF.  CUKMICAL   KXAMINATION   OF    rUNCTUUE-l-LUIDS      -Jl 

The  following  reaction  may  W  ustxl  to  lUtort  tlu'  pivsonci- 

of  oxydase  in  leucocytes  : 

A'rocentlvprcpartHlsolutionol  ..-naphtho!  in  waft  ( i  iHicent.). 
containing  l  inr  cent,  of  s.,.liuni  carbonate,  is  ,Hmvc,l  over  the 
tihn  and  left  for  one  or  two  nunutes.  After  a  momentary  wash 
in  distilled  water,  a  few  drops  of  I  l>er  cent,  a.p.eous  dnnethyl- 
naraphenylenediamine  (Marke  Sch«char<lt)  is  poured  over  the 
lilm.  If  blue  granules  api^ar,  oxydase  is  present.  Ihe  him 
.hould  Ix:  fixed  either  with  alcohol  or  with  formol  vapour.  he 
preparation  has  to  be  examined  m  water  and  will  not  keep.  1  he 
solutions  should  be  fresh. 

The  explanation  of  the  reaction  is  that  the  ferment  m  the 
granules  converts  the  twj  reagents  use.l  into  naphthol  blue 
according  to  the  formula  : 


,.  ,,  fdlNlCH,),. 
„H,[a]OH  +  O,  =  t,H.|^^|j^  ^  C,„H,[..10H  +  2H.,0. 


Eosinophile  granules  come  out  blue  also.  According  to 
Papix>nheim,  it  is  a  pyrrhol  reaction  (see  p.  ':>»). 

8  PerOXydase.  — O.  v.  Furtl.  has  ,loscril)e<t  a  nu-tho.1  of  cstimatinK 
tbis  f.rment  siuctrophotonu-trically  with  tlu'  aul  of  malachite  Rr.en.  He 
t^JlL  ferment  w.th.n  leucocytes,  so  that  one  nu^lU  expect  to  find  .ts 
presence  in  inflammatory  Ihiuls  or  purulent  exudates. 

^Whether  oxvda.e  an.l   peroxydase  are  specal   enzymes  ,s  uncertam. 
as  the  action  is  a  property  common  to  very  many  enzynus. 

9.  Catalase.  — JoUes'  an.l  Oppenhe.ms  metho.l  of  <letecting  catalasc 
involves  the  followma;  procedure :  ,■     •  ■„        t»„. 

(,<)  Preparation  of  a  ,-por-cent.  solutu.n  of  hylroRen  d.oxule.  The 
soht'on  .s  neutraUse.l  wUh  decnormal  soda,  and  t.trated  '"  I--"-  ° 
.sulphuric  acid  with  .lecinormal  potassium  permanganate  (standardised 
against  decinorma!  oxalic  acid). 

,  cc.   "^  oxalic  acid  ^  1701  mgm.  H ,0,:   '  '^'-■-  ,0  °""'  ''"'^  =  '  "'  lo  '^^'"^'• 

The  number  of  cubic  centimetres  of  permanganate  will  therefore  enaNe  the 
number  of  milligrammes  of  hydrogen  peroxide  present  in  >oo  -^0''"= 
solution  to  be  calculated.  I.  is  then  diluted  till  it  reaches  .  per  cent. 
The  "ithors  recommend  ix.rmanganate  titration  rather  than  the  io<lometr.c 

'"■'('^''Freparation  of  a  solution  of  so.lium  hyposulphite  to  estimate  the 
H  O  which  remains  unaltered  by  the  catalase.-(.\)  .5  «-•  -^'  '1-°'-;^ 
"-    -,  ,        ,   ,.    ,,-    ,.a.,  „,„    surest  notassium  bichromate  are  also 

111  a  litre  of  watel  .    ;l';    j  ■•/ i   ,-.'■■  r"'-'    .  , 

dissolved  in  a  litre  of  water  (20  cc.  of  this  =-  o-.o,  gm.  uxhneV  .0  c  o  thi 
second  solution  are  placed  in  a  stoppered  flask,  and  .0  cc.  of  .o-p^-cent.  KI 


78 


STl  lill>    IN    rL'NCTL'KIMI.riUS 


iiMi  il.      In  u\  <    iiiiiiiiti^  .I'M  I'll 


U.lli  I    .111,1    tlll.'ti-    till     IlKllllr   wuli    III 


M' 


l^llllilllti     -clllltllPlI   .I,L.M1II-1     ^l.lli    11 


p.i^tt   .1-.  iniliditiii'. 


I'..iili<iil 


U     lllltl- 


lUClK     II 


I    ll\|>' 


'lull 


-|iiinil~  III 


Jul 

II     III    H  .    II 


I  A 


Kill,  no 


Il  I    llil.iti    till    iIukI  III  III'  li'^ti  ij  ti 


P  " 


Ntiw  :i-.irn.im  i;i  muiiiIh  r  <it  iiiliic  iiiitiinitn -.  solution  \  imiliil  to 
ri.ii  I  \Mtli  jM  II,  III  till'  -.Liiiiliiril  ■-oliitioii  ol  II.O.  (ir.  niiiiilii  i  ut  i  nine 
1 1  iitiiin  in  ~  ^iiliiliiHi  \  iiiiiliil  111  n-.ut  wuh  ,i  nii\tmi-  ol  .;  n.  ol  llniil 
to  ill-  irsii .!    pill,    jii  II .  volution  III    IIO. 

n-ii     y   .r  );m.  ll_l»         No,  ul  cm.  II,' >.  i!cco:iipi.s»il. 

Tlir  linu   111  i\|iiisiirr  II,  til,    no,  ,hoiil,l  .ilwiiv.  In-  tlir  --.lire. 

Tins  tcriiifiit  is  most  likrly  to  Ik-  jMi'Sint  in  ctfusions  con- 
tuininK  lilood,  since  it  has  \x'vn  found  by  SillHMfjWt  and  Mosse 
tluit  till-  activity  o(  tlu-  catalytic  |)()wt'r  (U'ln-nds  on  the  varying 
content  ol  red  cells,  whether  healthv  or  diseased. 

lO.  Precipitins.  -  In  order  to  estimate  the  amount  of  these, 
Hamburger  employs  the  special  tubes  which  he  has  devi.sed 
(Fif^.  5).  'Ihe  serinn  and  the  antiserum  are  measured,  mi.xcd, 
and  then  centrifuged  till  the  precipitate  lias  a  constant  volume. 
The  e.xact  reading  is  made  with  the  help  of  a  lens.  This 
jirocedure  has  not,  so  far,  I'  "u  applied  to  puncture-fiuids. 


EXPERIMENTS    ON    THE    FERMENT-CONTENT    OF 
VARIOUS    SEROUS    EFFUSIONS 

The  accompanying  table  will  show  the  lesults  which  have 
been  obtained  by  testing  jieritoneal  and  pleural  fluids  for  their 
ferment -content.  The  most  convenient  methoil  of  applying 
such  tests  has  been  found  to  consist  in  using  short  test-tubes 
(4  by  \  inches)  duly  sterilised  and  plugged.  A  scries  of  four-ounce 
flasks  were  also  sterilised,  an  1  the  following  meilia  were  prepared 
in  them  :  a  thin  emulsion  of  boiled  starch,  i-per-cent.  solutions  of 
glucose,  hii  tose,  mannite,  (.lulcit.\  cane-sugar,  and  ordinary  ccn- 
trifuged  milk  coloured  with  litiiius.  loo  cc.  was  found  sufficient 
in  each  case.  A  number  of  the  sterile  tubes  were  then  filled 
with  these  media  and,  as  a  precaution,  further  sterilised  in  the 
usual  wa\-.  In  the  su.:i;ar  media  Durham's  tubes  were  inserted 
(preiiared  from  ordinary  glass-tubing),  tlie  air  being  expelled 
during  the  i)rocess  of  sterilisation  The  cotton-wool  plugs  were 
dyed  with  methylene  I'ue,  methylene  green,  aurantia,  saffranin. 


TMi;    .  IIIMKAI.    IXAMINATION    .'I     It   Nl  TUKK-I' l.LII.S      79 

au.l  gentian  v.ol..t,  >..  ;<^  to  ^h^uw^'u.h  tlw.,..  n.r.h.i  wt.uh  sure 
.(il'nuK'ss. 

In  tostm«  a  f^iv.i.  riiiM.  mu-  ..I  r.u  li  ol  tlu-r  ti.U-,  w.is  .  lur«nl 
w,tl,  a  small  <iuant.tv  (nut  in.aM.ml)  *  <-!  tl.r  tlui.l.  aivl  n,  .u^h 
,nl„(,l  a.l.lod  f.  f...  in  a  row.  .n^;  Du'  tulHS  urn-  .hak.-n  to  .  i>- 
tnl.utc  Huid  over  nuMlnim.  and  wnv  im  nbattd  at  .i7  f<>i  nthfi 
tw.lvc  or  twfntv-lour  hours  in  .Uttonnt  casts.  At  tlu-  rnd  of 
that  time  Itrnirntation  was  note.l.  if  j.irs.-nt.  and  tlu-  ivartion 

WiTtaincd  h\  drop^  ol  htnnis  solution. +     In  the  caso  of  star.h. 
the  nu.humwas  t.stid  tir.t  with  h.iu-.r  iodi,  and.  sm.ndly.  with 

1-ihlinK's  solution.     In  th.'  caM-  of  xhv  rani-.u«ar  Fohhng  s  t,st 

was  alone  applied . 

In  addition  to  these  media,  plain  te>t-tul.e>  of  the  same  size 
were  used  to  test  the  lipolytic  ferment  by  the  ethyl  butyrate 
method,  and  for  proteolvtic  ferments  t.y  the  use  of  Mett's  IuIk-s 
,n  (<0  acid  and  {f>)  alkaline  medium.  The  tuUs  were  not  used 
tor  (luantitative  tests,  but  were  found  convenient,  iind  the  egs- 
albumen  was  more  easily  and  more  economically  stored  m  this 

The   Reducing    Power  of    Puncture-Fluids. -This    is 

met  with  m  inflammatorv  exudates,  and  also  in  the  cerebrospinal 
fluid.  It  has  been  Ix-st  studietl  in  the  blood,  urine,  and  bile 
{Melon.  Migliarini). 

The  reducing  iwwer  of  i  cc.  of  blood  is  equivalent  to  U5  cc.  ol 
decinormal  KMn()4,  that  of  serum  to  51.  ^nd  is  found  to  be 
increased  in  pneumonia  and  diabetes.  The  chief  value  o»  the 
observations  lies  in  the  fact  that  the  reducing  i>ower  is  constant 
at  all  times,  but  it  varies  according  to  the  amount  of  kMn()4 
used,  according  to  the  action  of  the  light  and  according  to  the 
time  occupied  by  boiling  the  blood  with  the  KMn()4. 

Ferments  in  Leucocytes.-It  is  to  LcIkm  in  i8c,i  that  wo 
owe  the  discovery  that  aseptic  pus  has  the  power  ot  digesting 
proteid  matter.  He  fomul  that  such  pus  will  iiquety  gelatine 
at  25  C.  Not  much  notic  of  these  observations  seems,  however, 
to  have  Ix^en  made  till  Erlx-n  in  vpS  publisheil  an  account  of 
ferment  action  in  the  blood  ot  leuc;tmics,  shown  by  the  presence 
oi  albumoses.  a  tact  which  I^chunnn  pointed  out  in  specimens 

♦  Q«-intitativ-    ;.n;!!y.i-.    wa.    a-nwl    un.ucc^ary    .11    tin,    ^cn.■s    o( 
(.xiuriinonts. 

+   More  rapid  than  tliu  ii>c  ot  litmus  pap'-r. 


8o 


STri>n>    IN    1  INiTlKK-KI.UIDS 


of  hlood  i.Miuvia  po-t  iiioitiMii  liiMii  l.if.iiiiics.  Thi-  l>t<).).l 
sfiiiiii  coiitaiiifil  (U-iitiio-alhiimoM'-'.lN-  >iil>-t,inn-;.  anil  loiuiii 
ami    (viosin. 


lAiti.r.  X 


NatUK  of  >|.riiinrii. 


-      1       - 


J  -z 


iii 


«-| 


o 

V 

0> 


Iiihi  rriilar  I'lciu  i->y  ..■ 
Siinplr  I'lriii.il  KlVu-ion 
l.liopalliic  I'leuial  KlTu- 

siiill      ... 

Tiilii  H'lil.ir  ricurisy 

I  ardi.ic  l'.iiUiii 
Kmpjcina 

It  •  •  •  ■  *  ■ 

Postpncunionii'        Caii- 
tircno  (if  liini; 


Back-prpssiire  .. 
riibtriiilous 
Cardiac  Failure 

II  'I 

Chronic  Peritonitis 

II  I" 

rhosis  of  Liver) 
Cariinoniatosis 


tra.i'  ' 

o 

... 

" 

o 

. .. 

o 

o 

... 

o 

+  + 

+ 

+ 

0 

o 

o 


+  +  +  '  o 


iCir 


Polyiirrliomcnitis 

Atrophic  Cirrhosis  of 
I.ivtr 

Cardiac  Faihire 

Renal 

(Kdema  sine  Albumin- 
uria   ... 


+      '  ... 
O 

o 

+  t     ... 

+    i... 

o 
o 

o 

i 

+  +  o 
+  o 
o        o 


o 

+ 
o 


o 
o 
o 


o  o  o      o 

...  trati  

.  'raci  ... 

...  (lac.  ...   traci 


o    o 


.. .    o 
o 

. .   irai't 


I)        o 

o      o 


o 
o 
o 
o 
o 


+     + 
o     o 


+ 
o 

.  tract    ... 

■  :     +    :  ••• 
.  '    o    i  ... 


o 
o 

o 
o 
o 


o 
o 
o 


o     o 


+  + 
+  +■ 
o     o 


cma/  < 
luid\ 


CEdcma  /  Cardiac  Failure 
Flu 


g  I  Tanireatic  Cyst            ...         o 

^  -,  L'liitui-iilar  liroad   I.ig::  j              ; 

"u  mcnt  Cvst     f  t  + 

.£  Unilocular  Cyst            ...  ;  tr:ic<; 


o 

+ 

o 

0     o 

. . .   tr.icf 
0       o 

'i 

o 

J... 

0       0 

1 

1 

+ 

1  * 

1 

+  i  + 
t       1 

...     o      o 


TIIK  <  IIFMIi  AL    KXAMINATION    OK    IL'NCTLKK-Fl-UIDS 


8l 


To  MiilK-r  ami  Jochinann  wi-  owv  tli.-  further  discovory  that  if 
l-nruU-nt  sputum  »)<•  pl.uv.l  on  I.otfl.-r's  soruin.  (UK.-stioii  of  thf 
Uttir  will  take  plair .  and,  nior.-owr.  that  tlu-  hloo  I  of  Wuctinio 
l-aticnts  produces  the  same  solvent  effect.  The  soKvtU  action 
did  not  occur  if  the  hloo.l  had  In-en  heated,  a  Jact  which  j.rove.l 
that  the  leucocytes  of  leucanuc  »)lood  contain  a  ferment  capa»)le 
„l  it.tinK  on  <lrie<l  blood-serum.  This  ferment  is  a  j)roteolytu-. 
and  of  a  trvptic  nature.  Hesi.les  this  discovery,  there  is  that  of 
the  fact  that  the  serum  of  blood  contains  a  body  which  will 
inhibit  the  liquefvint;  action  of  pus-cells,  a  property  which  is 
aUo  thermolabile.  iH-ing  destroyed  at  a  temiK-rature  above  55   t. 

Many  other  ol>servers  have  corroborated  these  observations, 
tli..ui,'h  they  were  not  absolutely  new.  Thus.  Opie  found  that  in 
intlammatorv  exudates  due  to  bacterial  causes  a  proteolytic 
enzyme  was  present,  and  he  tested  it  by  the  eff.-ct  on  aleuronat, 
and  a  N-estimation  by  Kjeldahlising  after  coitjulation.  Opic 
also  noted  the  interfering  action  of  the  serum  on  this  leucocyte 
ferment,  and  that  it  was  thermolabile.  Ffeiffer  f.jund  the  pro- 
tiolytic  ferment  in  the  polymorphonuclear  neutrophile  leucocytes, 
which  explained  the  autolytic  processes  noticed  in  leucicmia. 
The  autolysis  was  estiinateil  by  the  amount  of  non-coagulable 

nitrogen. 

Stern  and  EpiK>nstein  showed  that  the  ferment  can  l>e  tletected 

just  as  easily  by  gelatin  as  by  blood-serum. 

The  interesting  fact  was  found  that  this  proteolytic  fjrmcnt 
will  withstand  admixture  with  formalin  ]K<rfectly  well,  so  that 
its  occurrence  can  be  demonstrated  in  si)ecimeni  that  have  been 
subjected  to  the  Kaiscrling  process  even  years  ago. 

Objection  has  been  made  to  these  facts  by  Baer,  who  iK)inted 
out  that  the  digestion  was  tested  for  by  the  use  of  a  denaturalised 
albumen,  and  that  the  process  could  not  be  compared  with  auto- 
hsis.  The  ferment  is  acting  on  a  foreign  albumen,  and  the  process 
is  therefore  heterolytic.  The  distinction  becomes  imjxjrtant 
from  the  fact  that  the  sj)lcen  of  cows  and  horses  can  show  auto- 
lytic effects,  but  cannot  be  made  to  act  heterolytically,  and  this 
absence  of  heterolytic  ymwcv  might  be.  looked  on  as  an  ant. ferment 
action  when  there  is  really  no  antiferment  action  in  the  jiroccss. 
We  may  say,  then,  that  the  serum  of  pus  contains  an  anti- 
ferment  lor  autolysis,  but  not  for  hctcroiysis,  while  the  pus-cells 
contain  a  ferment  for  autolysis  and  a  ferment  for  heterolysis. 

6 


I- 


!l 


82 


STL'DIKS   IN    I'UNCTURE-FLUIOS 


The  preponderance  or  otherwise  of  the  ])olyniiclear  leucocyte  in 
an  effusion  will  account  for  the  diminution  or  increase  in  the 
amount  of  antiferment  present.  Thus,  in  septic  diseases*  the 
antiferment  is  almost  abolished,  while  in  tuberculosis  antiferment 
is  present  in  increased  amoun*.  In  tuterculosis  the  effusion 
usually  contains  an  excess  of  lymphocytes  (see  Section  V.),  which 
are  not  characterised  by  ferment  granules.  In  ansemia,  whether 
primary  or  due  to  h:emorrhage  or  to  malignant  tissue,  the  anti- 
ferment-content  is  normal  or  even  diminished. 

Autolysis.-  -The  fact  that  autolytic  processes  may  occur  in 
exudates  and  transudates  seems  to  have  l>een  first  established 
by  Salkowski  in  i8()0.  The  problem  which  is  most  discussed  is 
as  to  whether  autolysis  is  in  any  sense  a  vital  i)rocess.  Wiener. 
Poll,  Langstein,  and  Neubauer  considered  that  autolytic  pro- 
cesses could  not  take  place  in  a  living  cell ;  but  in  order  to  establish 
this  it  would  be  necessary  to  ascertain  whether  autolysis  can 
occur  in  an  alkaline  medium.  That  this  is  actually  the  case  has 
been  made  out  b>  Drjewzki  (U)o(>). 

The  practical  value  of  the  subject  of  autolysis  lies  in  the  fact 
that  in  certain  flukls  no  autolytic  changes  are  to  be  made  out. 
The  existence  of  certain  ferment  reactions  might  be  accounted 
for,  on  the  other  hand,  by  assuming  autolytic  changes  to  have 
taken  place. 

Drjewzki's  method  of  study  was  as  follows  :    The  substance 

to  be  tested  is  diluted  with  water  and  75  per  cent,  chloroform 

is  added.     Another  mixture  is  alkalised  with  sodium  carbonate. 

A  third  mixture  is  boiled.     The  three  mixtures  are  incubated 

for  a  given  time,  then  brought  to  the  boiling-point,  made  up  to 

a  litre,  and  the  fluids  filterc.l.    Next  day  the  filtrates  are  concen- 

tratetl  to  400  cc,  and  in  the  filtrate  the  following  processes  are 

carried  out  :  (a)  From  20  cc.  estimate  the  X.  (Kjoldahl)  =  total  X. 

(h)  To  50  cc.  add  5  cc.  dilute  HCl  and  10  jx'r  cent,  phosphotungstic 

acid  till  a  precipi'tatc  ceases  to  fall.     The  filtrate  is  Kjeldahlised, 

to  get  iiwmimid-N.     (c)  50  cc.  receive  i  cc.  dilute  sulphuric  acid. 

Saturate  with  zinc  sulphate,  and  leave  to  stand  twenty-four  to 

forty-eight  hours.     The   precipitate  (albumose)  is   Kjeldahlised 

=  albumose-XA     (<0  100  cc.  are  alkalised  with  a  few  tlrops  of 


*  Wuns. 

t   Tlu'  procipitate  imi-t   W  IhoroUKlily  tlry  before   Kjcldalilisinfe    else 

the  flask  will  burbt. 


THE   CHEMICAL   EXAMINATION   OF   rUNCTURE-FLUIUS      S3 

ammonia,  and  the  phosphates  are  filtered  off.  Add  3  i>er  cent, 
ammoniacal  silver  nitrate  to  i)recipitate  the  purins,  an'l  after 
twelve  hours  (darkness)  the  precipitate  is  collected,  washed,  and 
Kjeldahlised  =  purin-N. 

a.—(h  +  c  +  d)  =  nitrogen  of    diamino-acid,    peptone,    and 

ammonia. 

The  following  results  were  obtained  in  one  of  his  cases  : 


Analvsi!<  «fter  72  hours' 
autolysi*. 


A 
without 
NajCOa 


H  CO 

with  .N».^0,       wiih  Na-iCOi.      co«|fulated  at 
and  ferments.  ;    no  ferments.    ,  once. 


% 
total  N 


% 
total  N 


% 
total  N 


% 
total  N 


Total  nitrogen 
Monamino  acids 
Albumoses    ... 
Purin  bases  ... 
Diatnino    acids 
pef  tones   ... 


6-545  ! 

4'022 
0-490 

o  826 


61 -60 

748 
.     62 


and 


4ii2q 

2-184 
0532 
0490 


...   !  3-570 

5316  !  172* 
1993  i  °6oi 
11  91  1  0049 


1197    183     09065I  1506    1198 


3-«5        - 
4823      •••     !     ••• 
«6-83  ;  0756  :  24 00 
1-37  i     ...     1     ... 

I         ! 

33-57  I     .  .     — 


This  shows  that  autolysis  still  occurs  in  an  alkaline  medium, 
although  it  is  true  that  she  velocity  is  much  slower  than  in  an 
acid  medium.  Column  D  is  a  control.  Another  answer  to  the 
question  as  to  ante-mortem  existence  of  an  autolytic  ferment  lies 
in  the  following  consideration  :  Why  should  a  ferment  exist  in 
a  cell  during  its  whole  life,  and  only  come  into  oi^eration  after 

the  death  of  the  cell  ? 

The  Importance  of  .4»/o/y,sts.-The  following  are  examples 
of  autolytic  decomposition  :  (i)  breaking  down  of  malignant 
tumours':  {2)  acute  yellow  atrophy  of  the  liver  ;  (3)  effusions  in 
process  of  absorption  ;  (4)  absorption  of  pneumonic  exudate— 
the  proof  of  this  lies  in  the  occurrence  tf  amino  acids  in  the 
urine  ;  (5)  relaxation  of  rigor  mortis. 

Besides  these,  the  pueri-K?ral  changes  taking  place  in  the  uteru.s 
and  the  changes  of  phosphorus  poisoning  are  examples  of  auto- 
lysis. It  is  natural  to  supjwse  that  if  autolysis  occurs  in  diseases 
associpted  with  effusions  we  should  be  able  to  find  evidence  of  it 
in  the  effusion  itself.  Consequently,  the  detection  of  albumose 
in  such  fluids  acquires  a  considerable  imiwrtance,  and  a  list  of 
the  cases  in  which  albumose  has  been  found  is  given  in  Table  II. 
It  is  there  seen  that  albumoses  frequently  occur  in  tul>ercnlar 


H 


STUDIES   IN   PUNCTURE-KLUinS 


l)leural  cases,  and  also  in  empyema.  In  a  purulent  effusion  one 
woukl  exix-ct  autolytic  jirocesses  to  take  place  in  any  case,  as. 
from  exi>erience  of  empyemas  which  have  been  opened,  one  has 
frequently  seen  a  digestive  action  being  exerted  on  the  exposed 

surfaces. 

In  the  case  of  i>eritoneal  fluids  albumoses  are  frequently 
l^resent,  just  as  jH^ritoneal  fluids  in  general  have  been  found 
much  more  complex  in  comi)osition  than  are  pleural  fluids. 

That  the  presence  of  albumoses  does  not  necessarily  mean 
lireceding  autolytic  processes  has  been  pointed  out  by  Magnus- 
Levy  and  by  Chvostek,  the  latter  having  found  albumoses  in 
the  urine  as  a  result  of  ulceration  of  the  intestine.* 

Again,  there  is  the  possibility  that  the  apjiearance  of  such 
bodies  as  deutero-albumose  in  a  fluid  may  be  the  result  of  hetero- 
lysis  (Jacoby),  some  ferment,  say,  in  the  li\er  having  something 
to  do  with  the  process. 

The  substances  which  demand  search  in  order  to  study  this 

]>oint  are  : 

(ii)  Leucin.  tyrosin,  glycocoU,  xanthin  bases. 

(h)  Annnonia,  cystin,  pentamethylenediamine,  lysin,  arginin, 
tryptophane,  asparagic  acid,  glutaminic  acid,  histidin. 
"  (c)  Thymin,  uracil,  H2S,  succinic  acid,  j^entoscs. 

((/)  Peptones  and  albumoses  are  merely  intermediate  pro- 
ducts. 

From  this  formidable  list  we  may  refer  especially  to  leucin, 
tvrrsin,  lysin.  arginin,  tryptophane,  as  these  have  been  most 
searched  for  in  jieritoneal  fluids.f  The  results,  which  will  be 
found  tabulated  under  the  various  headings,  go  far  to  show  that 
either  some  autolytic  changes  are  going  on  in  exudates  and 
transudates,  or  that  such  bodies  appear  as  the  result  merely  of 
accidental  transmission. 

TheonK  way  of  distinguishing  between  autolysis  and  extra- 
neous causes  ol  decomposition  is  to  watch  the  changes  which  the 
fluid  undergoes  on  being  kept  under  aseptic  conditions.  Such 
observations  may  be  made  without  going  into  lengthy  analytical 

*  Sucli  authorities  as  AlxlfrliaKlen  have  denied  that  albumoses  occur 
in  normal  blood,  while  Freund  asserts  that  the  methods  employed  for  their 
detection  in  blooil  have  not  been  sutticiently  sensitive.     (See  btochem.  Zeil. 

vii.,  p.  S4S.) 

t   Tlie  special  tests  lor  each  c     these  bodies  will  be  found  indicated 

under  their  respective  headings. 


THE  CHEMICAL   EXAMINATION   OF   PUNCTURE-FLUIDS      S5 


processes  by  determining  the  variations  in  the  electro-conduc- 
tivity of   the  fluid  from  hour  to  hour  (thymol   added),  since 
decomposition  of  proteid  would  result  in  diminished  inhibition 
of  the  conductivity  of  the  electrolytes  of  the  fluid  (cf.  p.  9)). 
The  following  results  were  obtained: 

TABLE  XI 
Autolysis  is  Punctlre-Fi  rit  s 


Duration  in    \ 
hours.  1 


At  outset. 
22 
46 
70 
92 

H7 
142 

170 
189 

3Si 


'lui  i  from  Ovarian 

Pleural  Fluid 

Cyst. 

Ruptured  Thoracic  Aneurysm. 

888-8  at  19-3°  C. 

843  at  23°  C. 

818 

889 

893 

... 

95 1 

960 

981 

1062 

1073 

985 

... 

1059 

■  •• 

The  figures  represent  the  changes  in  conductivity  (expressed 
in  terms  of  io-'>)  and  it  will  be  seen  that  in  each  case  there  was 
a  steady  increase  in  the  ionisation  of  the  fluid.  This  seems  to 
]X)int  to  the  existence  of  an  autolytic  decomposition,  though 
only  of  slow  develoi^ment  and  moderate  in  amount.  The  initial 
fall  of  conductivity  in  the  case  of  the  ovarian  cyst  is  jwculiar. 

According  to  Midler  and  Magnus-Levy,  the  autolytic  decom- 
position of  albumen  is  accompanied  by  breaking  down  of  lecithin 
and  of  CHO  groups  into  volatile  acids,  lactic  acid,  ami  succinic 
acid.     There  is  also  a  remarkable  .imount  of  ammonia  liberated. 

Ascoli  and  Izar  discovered  that  autolytic  processes  are  very 
greatly  accelerated  by  the  presence  of  inorganic  colloids  such  as 
colloidal  silver,  platinum,  or  gold,  .\rsenic,  on  the  other  hand, 
may  inhibit  oxidation  (C.  Foa). 

As  regards  the  location  of  the  enzyme  there  aio  two  possi- 
bilities to  consider.  In  the  first  place,  the  autolytic  ferment 
may  occur  as  an  endo-enzymo,  within  the  cells  of  the  puncture- 
fluid,  just  as  it  occurs  in  the  liver-cell,  the  spleen-cell,  the  lung- 
cell,  and  the  thymus-cell.  In  this  case  one  would  exjxjct  that 
on  filtering  the  fluid  the  ferment  would  l^e  removed.  The 
other  possibility,  however,  pievenis  this  from  affording  any 
definite  evidence.     That  is  to  say,  the  ferment  in  the  fluid,  just  as 


STIDIFS   IN    lUNCTL'RE-KLUIDS 


1^ 


is  the  case  with  anv  of  the  other  ferments  met  with  m  i-uncture- 
Ihmls  mav  have  beccme  hlx-ruted,  owing  to  the  breakmg  up  of 
cdls  ■  remnants  of  such  colls  are  easily  seen  in  any  film  prepara- 
tion "  In  whichever  situation  the  ferment  may  be.  the  hnal  result 
is  the  same,  and  it  is  a  uuai.r  of  no  very  great  imix>rtance  m 
which  way  exactlv  the  ferment  came  to  be  in  the  fluid  at  all. 

But  when  we  "consider  how  many  ferments  there  may  occur 
in  anv  one  cell  it  comes  tc  be  a  question  by  what  means  they 
cm  ail  be  accommodated  in  so  small  a  compass.     Pfeffer  and 
Hofmeister  considered  that  the  colloidal  structure  of  protoplasm 
allows  the  fe-.ments  to  be  within  the  cell,  distributed  not  only 
in  space    but   in  tune  within  the  cell;    and  Jacoby,  who   has 
contributed  many  papers  on  the  subject  of  ferments  and  anti- 
ferments  has  i.ointed  out  that  ferments  may  remain  in  a  state  ol 
zvmogen  for  a  long  time,  the  active  period  being  relatively  only 
a  momentary  one.     This  author  compares  a  ferment  to  a  toxin, 
and  supposes  it  possible  that  a  ferment  may  consist  of  a  hapto- 
phore  and  a  zvmophoie  group.     The  haptophore  group  would 
become  attached  to  part  of  the  cell  substance  and  lead  to  the 
formation  of  new  compounds,  which,  being  liberated  into  the 
serum   act  the  i)art  of  an  antiferment. 

It  is  interesting  to  note  that  the  solubility  of  ferments  is 

altered  by  the  presence  of  lecithin.     The  bearing  which  this 

obserx  ation  has  on  the  study  of  puncture-fluids  is  that  if  lecithin 

be  absent  from  a  puncture-auid  its  absence  may  account  for  the 

presence  oi  absence  of  any  given  ferment.  .,.«.„ 

Antiferments  —The  nature  of  antiferment  reaction  is  difficult 

of  <tudv   and  indeed  it  is  a  very  great  matter  for  debate  as  to 

whether  the  phenomena  assigned  to  the  presence  of  antiferments 

are  i-ally  the  result  of  specific  entities  at  all,  and  not  rather  the 

effect  of"  adverse  conditions  of  a  general  nature      It  is  easy  to 

see  that  if  a  givtn  ferment  does  not  receive  activation  to  exactly 

the  degree    .equisite   for  its  action,  an  apparent  inhibition   of 

action  might  occur.      Under  such  circumstances  the  observer 

nught  assume  that  there  was  an   antisubstance  present  when. 

in  point  of  truth,  the  effect  is  due  to  the  absence  of  a  particular 

activator.  ,.    ^  .u 

There  are  manv  arguments  in  favour  of  the  idea  that  there 
is  no  such  thing  as  an  antiferment  per  se.  The  term  "  anti- 
ferment "  may  be  used  in  two  senses  :    it  may  either  mean  a 


TIIK  CHEMICAL   EXAMINATION   OK   PUN-CTURE-FLLIDS      S; 

jcnuent  exhibiting  projierties  antagonistic  to  those  of  an  ordinary 
ferment,  or  it  may  mean  a  substance  which  interferes  with  the 
action  of  a  ferment. 

The  foU-ving  facts  may  tend  to  show  that  antiferments  do 
not  exist  :      he  catalytic  decomixisition  of  hydrogen  peroxide 
can  be  inhibited  bv  the  adcUtion  of  NaCl  (Lockemann) ;  blue 
light  inhibits  catalysis  ;   i)eroxyda^e  cannot  convert  pyrogallol 
into    purpurogi.  ''a    unless    hydrogen    dioxide    Iw    present,    or 
unless  an   iron   compound  such  as  h;emoglobin  be  present,  or 
unless   NaCl  *   be  present  ;    iK'ptic  digestion   can   be  inhibited 
by    amino-bodies    (Jastrowitz)  ;    tryptic    digestion    can    be   in- 
hibited by  the  presence  ot  excess  of  NaCl  and  other  neutral 
salts,   and  esi>ecially  by  sulphates.     Fuld's  experiments  show 
that  the  appearance  of  antiferment  can  also  be  mimicked  by 
those  reactions  in  which  the  order  of  addition  of  the  reagents  is 
of   imiwrtance.     This   is   exemplitied   by   the   need   for   adding 
potassium  ferrocyanide   to  acetic  acid  in  the  test  for  proteid, 
and  not  vice  versa.     Possibly  something  similar  will  prevent  or 
allow  a  ferment  action. 

The  exi^eriments  which  Hedin  made  with  charcoal  and 
trypsin  might  be  interpreted  in  favour  of  the  idea  that  antiferment 
action  does  not  dei:)end  on  any  specific  substance. 

We  see,  then,  that  certain  ferment  actions  can  be  brought 
to  a  standstill  or  prevented  from  occurring  altogether  by  the 
occurrence  of  certain  antagonistic  conditions.  It  is  as  reason- 
able to  speak  of  blue  light  as  anticatalase  or  of  chloroform  as 
antitrypsin  as  it  is  to  give  a  si^ecitic  name  to  any  "anti- 
ferment." 

If  antiferments  really  exist  one  must  rely  upon  biological 
exiieriments  to  establish  the  fact.  The  most  important  evidence 
is  certainly  furnished  by  such  hemolytic  phenomena  as  have 
been  carried  out  by  Morgenroth  and  many  others.  Thus,  the 
injection  into  a  rabbit  of  a  ferment  will  result  in  the  production 
of  a  serum  which  has  the  power  of  rendering  the  particular  ferment 
inactive.  On  the  other  hand,  Liebermann  found  that  active 
rabbit  immune  serum  only  prevents  hajmolysis  if  calcium 
chloride   be   present.     In   this  connection   the  observation    by 

*  Thi.  tart  imparts  an  inestimable  importance  to  the  presence  of  so<iium 
chloride  m  the  bo<ly.  with  respect  to  the  depenaence  ot  every  me.abotiC 
process  upon  it. 


88 


STLDIKS   IN    I'UNCTURK-KLl'IDS 


Wohlgeimitli    that    locitliin  activates 
pancreatic  juice  also  derives  s|vcial  iin 

IK) 

as   antifeniients.     Kveii 


it  onlv  salts  hut  liimids  may  have  some  ] 


he   hii'Uiolytic   action  of 
portance  as  showing  that 

.ome 

tlu 


the   existence   ot   antiterments    m 
I  spec  iallv  treatt  1  rablnts  does  not  prove  that  antiferinents 


serum  ot  sj 

exist  in  the  luxly  natr  ally 
It  is  specially  >iiin   ican 


t  that  Heit/kt'  and  Neulx>rg  describe 


ti-emulsin  a>  connected  with  the  globulin 


an  an 

we  have  seen 


fraction,  when 


that  lecithin  is  also  associated  with  tfie  globulin 
fraction.      lacobv.  in  his  sununary  of  his  opinions  on  the  nature 


of 


ferment  action,  sav; 


The  fact  that  rennet  antl  pepsni  can  bt 


separated  from  hbrin  l)y  alkalies,  whilst  rennet  is  se|)arated  frcm 
antirennin  bv  acid,  is  in  favour  of  the  view  that  the  union  of 
ferment  with  substrate  is  not  the  same  as  the  imion  of  ferment 
with  antiferment."  The  association  of  antiterments  with 
globulins  reminds  us  that  the  action  of  an  antiferment  may 
merely  be  one  of  alteration  of  electrical  charges  in  the  colloids 
C(mcerned  in  the  reaction. 

Out  mere  consideration.  In  the  case  of  trypsin  it  is  now 
well  knf)wn  that  without  enterokinase  this  ferment  will  not  act 
on  i)roteicl.  Suppose  now  that  this  fact  were  not  known,  one 
would  have  found  that  certain  solutions  would  not  digest  proteid, 
and  have  assumed  that  these  solutions  contained  antiferment 
(antitryjjsin).  The  truth  is,  of  course,  that  the  activator  of  trypsin 
is  merely  absent.  But  suppose,  further,  that  the  enterokinase 
cculd  be  interfered  with  by  some  other  body,  then  we  shall  be 
introducing  a  third  factor  into  the  case,  and  it  would  be  rea,s(  n- 
able  to  descuDe  this  third  body  as  antiferment,  though  its  name 
would  be  anti-enterokinase.  and  not  antitrypsin. 

It  is.  however,  out  of  place  to  discuss  this  subject  further, 
although  the  amount  of  information  which  is  being  ga-hered 
together  liy  observers  in  all  countries  is  increasing  by  geometrical 
progression  So  much  is  this  the  case  that  it  becomes  almost 
impossible  to  fix  the  state  of  knowledge  on  the  subject.* 

*  Tlu-  vitws  ahoM'  expressed  were  written  down  before  the  work 
••  Uecent  .Advances  in  i'hysiology  and  Biotheniistry  "  came  to  notice. 
The  whole  siihji-ct  ot  leriiient  action  is  so  lully  dealt  with  there  (by  Prof. 
B.  .Moore)  as  liardlv  to  need  supplement.  On  the  other  hand,  many  valu- 
able contributions  have  appeared  since  Its  publication,  in  ihv  Biot'.cmual 
Journal,  in  the  liiochemischc  Zcitschrift.  etc.,  as  also  a  work  by  Schade. 
••  Diabetes  und  Katalysc."     Many  of  the  references  to  literature  for  KJ07 


THE   CIIKMKAL  FAAMINATION   OF   PUXCTUKK-FI.UIKS      89 

Method  of  Detection— The  tact  that  pus-cells  contain  a 
proteolytic  ferment  which  will  produce  a  small  <limi)le  in  Loftlir's 
iilood-.^erum  *  at  the  seat  of  inoculation  after  incubation  at  50  C. 
tor  twenty-four  hours  furnishes  the  means  of  detectinn  anti- 
l>roteolytic  ferment  in  a  Jjuncture-Huid. 

One  part  of  the  fluid  to  Ix-  tested  is  treated  with  from  5  to  20 
parts  of  pus,  and  a  drop  of  the  mixture  is  added  by  means  of  a 
platinum  loop  to  the  serum  tulw.  or.  as  Miiller  and  Jochmann 
advocate,  a  plate  of  serum,  which  has  the  advantaf,'e  of  ease  in 
working,  and  also  the  advantage  that  the  same  plate  will  serve 
tor  many  experiments. -t 

If  the  serum  shows  liquefaction  after  incubation,  then  the 
proteolytic  ferments  of  the  leucocyte  have  not  been  interfered  with, 
and  therefore  there  is  no  antiferment  present  in  the  fluid.  On 
the  other  hand,  liquefaction  may  not  occur,  in  which  case  one 
assumes  that  antiferment  is  present. 

The  pus  nuist  be  freshly  obtained,  and  must  be  sterilised  by 
addition  of  toluol.  The  pus  used  must  not  be  tul)erculous.  since 
tuberculous  pus  contains  no  proteolytic  ferment. J 

Antiferment  may  be  estimated,  according  to  Ed.  Miiller,  l)y 
ascertaining  how  many  times  fresh  pus  has  t(j  be  diluted  before 
the  fluid  to  be  tested  will  prevent  it  from  liquefying  the  dried 
Loffler's  serum.     For  blood-serum  the  normal  limit  is  75. 

The  method  of  detection  of  antiferment  §  may  be  applied  to 
Epiwnstein's  method  for  detecting  proteolytic  ferment,  which 
has  the  advantage  of  employing  a  readily  prepared  medium. 

The  fluid  to  be  tested  is  mi.xed  with  10  jier  cent,  gelatine  con- 
taining I  jx-r  cent.  soda,  and  a  similar  quantity  of  085  jK-r  cent, 
saline  is  added  to  another  portion  of  the  same  gelatine  (to  furnish 

and  1908  will  be  lounil  in  the  Bibhosraphy  on  page  z(<3  of  this  work, 
though  only  those  names  are  included  which  have  been  mentioned  in  the 
text.  Investigations  are  being  made  in  order  to  be  able  to  present  as 
full  evidence  on  this  problem  as  possible. 

•  The  serum  is  cow  serum,  and  contains  glucose,  or  8  per  cent.  XaCI. 
t   Tlie  chief  disailvantage  lies  in  its  manufacture. 

*  This  fa:t  may  be  of  use  for  distinguishing  tuberculous  from  other 
sources  of  suppuration. 

§  It  must  be  understood  that  these  methods  demonstrate  an  anti- 
ferment action  without  by  any  means  indicating  tlie  existence  of  a 
.specific  antibody.  It  will  Ix-  remembered  that  even  .an  .-mtitnxin  is 
acting  in  virtue  of  special  colloidal  properties  without  necessarily  con- 
stituting an  mtity  or  a  substance  capable  of  being  isolateil. 


90 


STUnil.S   IN    I'L'NCTL'RE-FHins 


u  control).  Botli  an-  incubated  for  twelve  hours  at  body  heat. 
( )n  removal,  both  Petri  dishes  are  set  on  ice  until  the  saline  s.impie 
(control)  has  set.  If  proteolytic  ferment  be  present  the  gelatine 
will  no  longer  set.  while,  if  antiferment  be  present,  or  if  there  be 
no  ferment  at  all,  the  gelatine  will  set. 

To  apply  this  test  for  detecting  antifernients,  it  is  obviously 
only  necessary  to  add  t  .hiolated  fresh  pus  to  the  fluid,  and  see 
the  effect  on  the  gelatine.  It  is,  however,  convenient  to  use 
ordinary  leucocytes  in  place  of  the  pus,  and  a  small  quantity  of 
blood  may  theiefore  be  collected,  washed  in  citrate,  and  then  in 
saline,  exactly  after  Wright's  method  for  getting  leucocytes  for 
opsonic  index  determinations.  For  the  small  quantity  of  fluid 
to  be  tested  this  will  furnish  readily,  and  at  any  time  or  place, 
the  necessarv  means  of  carrying  out  this  modified  test. 


SECTION    II 

THE   PHYSICO-CHEMICAL   EXAMINATION   OF 
PUNCTURE-FLUIDS 

Contents.     (A)  Osmotic  prt-ssure— Theoretical  considerations  on  osmetic 
pros-iuro  :    how  to  calculate  the  ounotic  (iressure  ;    the  decree  of  dis- 
sociation-Theoretical   considerations    on    electroconductivity  ;     cor- 
rections necessary  for  variations  in  temperature  and   in  amount  ol 
proteid  in  the  solutions  examined;    achloride    electrolytes   -Osmotic 
concentration- -Theoretical  considerations  dealing  with  the  elfect  ol 
mixtures  of    many  substances  on  the  freezin;j-paint  depression  and 
on    electroconductivity     The    relation    of    Ireezin-  point    depression 
to  specific   Rravitv-  Methods  of  determining   the   freezinjj-point   de- 
pression an.l  the  electroconductivity,  -Results  oi  examination  in  eacli 
case -The  plasmolvtic  Tnetho<l  ;  HamlnirKers  adaptation  to  the  study 
of  l)o<lv-fluids  ;  Wrights  method  -Other  methods  of  determination  of 
osmotic  pressure.     (B)  The  critical  solution  jwint.     (C)  The  concentra- 
tion of  the  hydrogen  ions  ;   theoretical  considerations  ;  meaning  of  the 
term  acidity     The  indicator  method  of  estimating  the  reaction  of  a 
fluid   -The  '  inversion    method     The     methyl-acetate     metho.1     The 
.lilatometer  method -The  diazoacetic-ether  methal   -The  concentra- 
tion-chain method  ;  the  gas  chain  ;  a  few  details  as  to  the  method  of 
carrying  out  this  methoil  ;    the  results  which  have  been  obtaine<l  by 
Foa'  and  by   I'faundler -Significance  of  the  results.     (D)  Viscosity 
—The  X  isco'simeter  of  Hess  ;  method  of  use  ;  the  theory  of  the  instru- 
ment ;  results  of  examination  of  puncture-fluids.      (E)  Kefractometry. 

The  constant  interchange  of  substance  between  the  cells  of  the 
body  and  the  fluids  surrounding  them  de[x;nds  to  a  large  extent, 
if  not  entirely,  upon  a  series  of  processes  which  come  under  the 
domain  of  physico-chemistry.  Not  only  do  we  have  to  deal  with 
a  series  of  chemical  reactions  between  living  substance  and  the 
matter  comi>osing  its  outer  world,  but  we  have  to  deal  with  pro- 
cesses of  diffusion  and  of  osmosis.  Osmosis  is  si>ecially  important 
in  the  case  of  puncture-fluids,  as  it  atcounts  for  so  many  of  the 
phenomena  that  they  exhibit.  A  consideration  of  the  factors  on 
which  osmosis  dejiends  is  therefore  needed,  although  those  theo- 
retical considerations  which  deal  with  the  question  of  pouring  out 

9» 


92 


STl  I)li:s  IN    I'L'Nt  TL'KK-H.lins 


(if  thii<ls  into  tli«'  st-rous  cavitu-s,  iiml  i>i  atisorption  Ironi  them. 
Iiavf  loiiu-  tr.  Ik-  so  sjH'cial  a  subjfct  that  nffu-nce  to  it  does  not 


COIIK 


within  the  ()l)jf<t>  of  thiN  woilc. 


(A)  Osmotic  Pressure.  When  a  sul)stance  is  dissolved  in 
wattr  the  niolecules  ot  tliat  >nl)stance  are  evenly  distrif)Hted 
tliioiiKlKtut  the  water,  and  exert,  not  only  a  pressure  on  each 
other,  hut  also  on  the  walls  of  the  rontaininj^  vessel.  The  pres- 
sure transmitted  to  the  (onhnes  of  the  fluid  in  the  endeavour 
of  tile  molecules  to  occupy  a  larger  spice  is  called  the  osmotic 
pressure  of  the  tlui<l. 

i'iic  law>  wliidi  f,'ovcrn  tlie  osmotic  pressure  of  a  solid  dissolved 
in  water  have  i)een  found  i)y  van't  Hoff  to  k'  identical  with  those 
which  olitain  wlun  a  |,ms  is  dissolved  in  water.  In  other  words, 
a  solid  tlissolved  in  water  behaves  like  a  gas  dissolved  in  water. 
If  thire  he  several  substances  in  solution,  then  the  total  osmotic 
pressure  is  ecpial  to  the  sum  of  the  osmotic  pressures  exerted  by 
each  sui)stance  taken  separately. 

The  osmotic  jiressme  of  a  solution  varies  according  to  the 
temi)erat\ue  of  the  solution  as  well  as  according  to  the  number  of 
molecules  present.  .Ml  solutions  which  contain  the  same  number 
of  molecules  in  the  same  volume  of  fluid  e.xert  the  same  osmotic 
in-essure.  In  other  words,  all  equimolecular  solutions  exert  the 
same  pressure. 


I'rtssiirc   X   volume   = 


prrsMire 
comintralii'ii 


constant. 


It  is  obvious  that  the  only  variable  will  be  the  weight  of 
the  molecules,  so  that  if  two  substances  be  dissolved  in  a  given 
volume  of  solvent,  the  osmotic  pressure  of  each  sdution  will  be 
related  to  the  other  according  to  the  molecular  weights  of  the 
dissolved  substances. 

It  is  on  this  fact  that  one  of  the  methods  of  determining  the 
molecular  weight  of  a  substance  deiH>nds,*  but  it  also  affords  a 

♦  Till'  tt)ll()\vinK  law>  have  liitn  fo\in<l  to  hold  good  in  llu'  cast-  of  ^iml)U■ 
soliition-i  ;  (i)  A  solution  trcizi's  at  a  lower  tt-niperaturi'  than  its  solvt-nt  ; 
(2)  tlu-  (Upri'ssion  ot  freezing-point  is  proportional  to  the  concentration  of 
the  solute  (BluKden.  178.O  :  (s)  equimolecular  solutions  of  the  same  soUent 
have  the  same  freezing-point  ilejiression  (de  Coppet,  187 1).  In  1882-4 
Raoiilt  -u1-^tanti;itid  tbi-;  l:i\v  for  iii.iny  ori.'.in!C  .substances,  and  introduced 
the  term  molecular  depression  or  freezing-point  constant.  .\t  this  time 
(.ryoscopyuas  invoked  lor  determining  the  molecular  weight  of  a  sul)stance. 
in  1888  Beckmann  introduced  his  thermometer. 


niVSKO-CIIEMICAL   EXAMINATION 


93 


iiirans  of  estimating  tho  o^notic  pri'ssuio 


of  a  nivtn  fliiitl      J"-** 


if  LMs  from  liquid  (K'tnands  tho  fXiR-nditniv  of 


solution  to  l)t>como  more 


as  tlu-  conversion  of  g^ 

work,  so  work  is  needeil  in  causing 

concentrated,  that  is.  to  ac«iuire  a  higher  c«motic  pressure 

If  we  determine  the  amount  of  work  (osmotic  work)  wlucJi 
is  ,x>rformed  in  ju^t  causing  solvent  and  <lis>olve.;  sul)stance  (a 
solution  of  known  concentration)  to  separate,  we  can  calculate 
the  amount  of  pressure.     If  a  solution  l>e  frozen.  i<e  will  separate 
„ut  as  the  soluti..n  U-comes  col.ler  an.l  coMer.  while  the  re.nain.ng 
tlui.l  is  constantly  becoming  more  an.l  more  concentrated.      Ihe 
molecules  in  this  solution  are  thus  In-ing  continually  forced  to 
occupy  a  smaller  volume.      In  nr.ler  to  effect  this  change  the 
osmotic  pressure  which  they  are  exerting  is  U-ing  over.-ome  by 
external  work,  and  this  necessitates  the  removal  of  more  heat 
than  is  necessary  to  cause  the  pure  solvent  to  freeze      llu  heat 
«f  fusion  remains  constant,  so  that  the  effect  of  the  external 
work    is    to    lower    the    freezing-ix,int.      In  other   words,   the 
solution  freezes  at    a    lower   tem,x>rature  than    that   at    which 
the  solvent  alone  would  freeze.     It  is  this  fact  which  underlies 
the  use  of   cryoscopy,  that  is  to  say,  the  determination  of   the 

fieezing-i)oint  of  a  fluid.  ,.      ,      ,   • 

SupiK)se  that   X  grams  substance  are  dissolved  my  grarm 
solvent,  and  that  the  depression  of  freezing-iK)mt  is  then  .-  L., 


Ihcn  I  pm.  substance  dissolved  u.  y  gm.  solvent  will  cause  ^  depression. 
I  gm.  mol.  (M.)         ,.  y  ••  ' 


and  I 


ICO 


X 
X 

Mzv^ 
luox 


■  nioticiilar  " 
ileprcssion. 


The  molecular  depression  is  a  constant  (k).* 

For  our  purposes  we  wish  to  know  .v,  so  that  the  equation 


become 


Mzy 
ICO  k. 


and  supposing  there  were  only  one  substance  present  m  a  given 
solution  (usually  water),  we  could  readily  ascertain  how  much 
substance  wa,  present,  o. .  in  other  words,  we  should  be  able  to 


*   K  for  water  is  18-5. 


94 


STUDIES   IN    lUXt  TL'KK-KLUIDS 


iwr  t)ii->  nutlKxl  tor  |nir|M>si<s  of  (|ii;iritit.iti\c  .malysis  of  a  fttiid. 
litlort'  this  ( ail  1h'  iloiic  \\v  have,  liowcvci ,  to  disc  u^s  tlif  fffii  t 
on  the  alH)Vf  tormiila  whtti  we  an-  iltaliiij,',  not  with  one 
■<iil)stan(f,  l)iit  with  several  sutNtanrt-s,  in  solution  ;  and,  nion- 
ini|Hirtant  still,  wo  liavf  to  ilisciiss  tho  rff''(  t  of  s(»lution  on  sul)- 
stanifs  ot  various  kiiuK.  When  scvt-ral  sul>stanci's  occur  <lis- 
xilvcd  in  water,  van't  Hotf's  law  tells  us  that  the  total  osmoti«- 
pii'ssuri'  is  ci|ual  to  the  sum  of  the  osmotic  pressures  of  «'ach  taken 
sepatately.  and  it  i>  tound  that  every  riS5  depression  of  free/.in^- 
l)oint  indicates  the  pressure  ♦  of  one  ^ram-molecule  of  sul)stance 
in  each  litre  of  water. 

riie  tact  that  the  ecjuation  ^iven  does  not  holil  ^ood  for  every 
individual  >ul)st  nice  brings  u|)  the  imiMirtant  (juestion  of  dis- 
sociiilioH  iij  Siills  when  in  solution.  A  solution  of  salts  such  as  is 
met  with  in  urine  shows  a  much  greater  free/.ing-iKiint  depression 
than  its  concentration  would  lead  us  to  ex|x'ct.  and  the  same 
lioltis  good  for  puncture-fluids  where  sodium  chloride — though 
the  most  conspicuous— is  not  the  only  salt,  but  occurs  associateil 
witii  sulph.iles.  phosphates,  and  carbonates  of  potassium,  calcium, 
and  magnesium.  To  take  the  case  of  NaCl  alone,  the  formula 
above  given  would  lead  us  to  exjiect  that  a  gram-molecular  solu- 
tion o.  sodium  chloride  (i.e.  a  solution  containing  58-5  gm. — 
the  molecular  weight  in  grains— of  sodium  chloride  in  each  litre 
of  water)  should  have  an  osmotic  pressure  of  185  x  1205  atmo- 
spheres, liecausc  all  gram-molecular  solutions  in  uater  freeze  at 
1-85  {'..  and  e.ich  degree  of  depression  of  freezing-point  means 
.m  osmotic  pressure  of  1205  atmospheres  (Kaoult).  As  a  matter 
of  tact,  the  solution  referred  to  has  an  osmotic  pressure  of 
^•51  X  i_'()5  atmospheres,  for  its  freezing-|K)int  is  5-51 '  C.  This 
discrepancv  was  exi)lained  by  .\rrlienius,  who  showed  that  when 
a  salt  is  dissolved  in  water  it  breaks  up  into  electrically  charged 
ions,  without  which  the  resulting  tluiil  would  never  be  able  to 
conduct  an  electric  current,  and  without  which  the  fluid  would 
not  exert  as  great  an  osmotic  jiressuic.  It  is  clear  that  if  a 
solution  of  NaCl  contains  not  only  NaCl  but  also  Xa  and  CI  ions. 
the  resulting  number  of  constituents  present  is  greater  than  if  all 
the  NaCl  has  remained  as  Na(T.     The  conception  that  the  in- 

•  I'ltltiT  tound  tli.it  It  .1  Kr'>"i"iol^'^'"l<'  oi  any  substance  Ih'  dissoiMii 
in  j.;i  ^  litris  ol  wattr.  such  a  solution  will  i  xirt  an  osvnotic  prtssuri'  ol 
one  atinospluri'  at  o"""  C. 


I'llVSICO-CIIKMUAL   EXAMINATION 


95 


.Uvi.Uuil  ions  a.t  )ust  its  intU'|H'n.Unt  inolrciiks  ami  txtit  an 
oMuotic  pressure  which  forms  the  |..th  of  the  theory  of  electro- 
Ivtie  .liss,K-iat.on  -explains  the  tart  that  the  free/.inK-ix»i"t  .U- 
,,ression  of  the  solution  is  Kreater  than  it  shouUl  hav  U-en.  As 
,.K)n  as  sodmm  chloride  is  (liss.)lve(l  m  water  some  of  it  .lissociates 
into  Na  and  CI.  each  of  which  adds  to  the  osmotic  pressure,  an.l 
,,Ko  enables  an  electrical  current  to  pass.  In  this  way.  then  the 
.  lectroconductivity  of  a  flui.l  is  de,H.ndent  .m  the  same  mtluences 
iis  is  the  free7.inK-l>oint  depression.*  Ami  the  mention  of  this 
tact  in  this  place  will  enable  us  to  understand  the  link  binding 
the  electrocomluctivity  method  of  research  to  the  cryos  ..pic 
iiuthod  which  is  dealt  with  in  the  present  work. 

To  return  to  .he  solution  of  NaCl.     Such  a  solution  contains  : 

fN«(l  ■♦    >Na  +.v<l. 

1  he  o.smotic  pressure  exerted  by  xSa  is  the  same  as  that 
exerted  by  )<:i.  for  though  the  ions  have  different  atomic  weights, 
it  is  the  actual  numlier  of  ions  that  is  imiwrtant. 

The  osmotic  pressure  of  the  ions  will  therefore  Ik-  : 

I  KS  +  I  66  =  3  SI. 

The  ions  and  molecules  of  the  other  salts  present  in  the  cited 
example  of  urine  will  add  to  the  osmotic  pressure,  m  ..cordance 
with  van't  Hoff's  law,  and  the  principle  remains  the  same.  Flie 
...motic  pressure,  and  with  it  the  freezing-ixjint  depression,  is 
produced  by  NaCl,  sodiun.  and  jKitassium  and  calcium,  etc. 
sulphates  and  phosphates,  etc.,  />/»s  Xa  and  CI  and  S()4.  an.l 
PO4,  and  Ca  and  K,  etc..  etc. 

If  the  solution  of  all  these  salts  Ix-  ren.lered  more  dilute,  the 
.lissociation  will  increase,  and  the  ratio  l>etween  un.lissociated 
and  dissociated  salt  will  alter  more  and  more  until,  theoretically, 
at  infinite  dilution,  there  will  only  be  free  ions  present.  \\ e  wi>li 
to  kn.)w  how  the  proportion  between  molecules  and  ions  can  bo 
ascertained  in  a  given  solution.  The  method  of  calculating  this 
can  be  indicated  by  reverting  once  more  to  the  simple  example  of 

XaCl.  .     .         ,       ,. 

It  has  been  state.l  that  a  gram-molecular  solution  of  sodium 

chloride  freezes  at  -3-51'  C.  instead  of  at  -rSs^     This  solution 


♦  N.B. — Ininase 


in  "  trtfzing  point  il.j)n-.-.ion 


i-ans  :i  />(//  ol  t.-m- 


piraturc. 


96 


STUDIES  IN   I'LNCTURK-KI.UIDS 


therefore  l)eli;ivts,  not  like  a  gram-molecular  solution,  but  like 


a   solution   containing 


J-5I 
1-85 


;    189    grpm-niolecular    solution. 


In  otiier  words,  by  dissolving  the  gram-molecule  of  XaCl  in 
water  we  have  niatle  it  have  the  same  osmotic  jiressure  as  if 
we  had  made  a  i'8()  gram-molecular  solution  of  undissociateJ 
substance.  In  other  dilutions  the  number  will  be  difterent  again, 
for  the  more  a  substance  is  diluted  the  greater  will  be  the  dis- 
sociation, but  Wf  can  determine  the  ratio  of  the  true  to  that  of 
the  theoretical  (calculated)  osmotic  pressure  in  the  way  indicated. 
Putting  the  facts  into  a  formula,  we  have  : 


dctrre  of  ilissoci.ition  "a"  = 


IrcczinK-point  found 
trt'ezinir-pnint  calculated 


—  I 


iiuinbir  ot  luns  in  one  moleiulc  ol  salt  —  1. 

In  the  above  example,  for  instance, 


3  5' 

2  - 


1  Sq  —  I 


-  0-89. 


That  is  to  say,  oSijof  the  gram-molcule  has  dissociateu.  and 
only  (jii  has  remained  undissociated. 

I'nfortunately.  however,  the  tluitls  under  consiileration  are 
not  solutions  of  NaCl  only,  but  of  a  numlx?r  of  other  substances, 
an.l  it  becomes  a  matt(>r  almost  of  impossibility  to  give  a  value 
for  the  amount  of  dissociation  when  we  do  not  know  how  much 
there  is  of  each  salt  present.  Not  only  this,  but  there  are  sub- 
^♦.mces  present  in  a  puncture-fluid  which  introduce  the  further 
com])lication  that  they  have  the  power  of  j)reventing  the  salts 
from  dissociating  as  fully  as  they  otherwise  would.  They  inhibit 
the  dissociation  of  the  constituents  of  the  fluid. 

However,  by  making  use  of  the  term  osmotic  concentration 
(C  ),  which  was  introtluceil  by  Hamburger,  we  can  obviate  this 
<lit"ticu!ty  to  a  certain  extent,  since  every  molecule  or  ion  causes 
a  freezing-i)oint  depression  of  185.     The  fraction: 

liccziiijr-pniiit  found 
'•»5 

gives  the  osmotic  concentration  of  the  total  number  of  molecules 
plus  ions  in  each  litre  *  of  fluid. 

*  'rtie  n.iiit  ot  tlijii]  sJiouM  ill-  i»iv(.-n  ill  p;r;tninirN  rtn<!  not  in  rnbir  ronti- 
iiietros.  It  will  hccx  idcnt  that  1,000  tc.  of  Huid  wcif^li  more  than  1,000 cc.  ol 
wator  liy  llu'  woight  of  dissoh  td  substanci'.  If  tlic  spocilic  gravUy  be  g,  I  litre 


isasHTp-i-.'Sr 


PHYSICO-CHEMICAL   EXAMINATION 


97 


It  is  now  necessary  to  refer  to  the  subject  of  cledrocondudivity 
in  order  to  give  a  more  correct  idea  of  the  constitution  of 
the  jHincture-fluids,  which  forms  the  subject  of  the  present 
studies. 

A  fluid  "vill  only  conduct  electricity  p.ovided  that  there  is 
some  dissociated  substance  (called  an  electrolyte)  present  in  it. 
Absolutely  pure  water  would  not  conduct  electricity  at  all  (i.e. 
it  is  a  non-electrolyte).     For  this  reason  we  may  employ  a  deter- 
mination of  the  electroconductivity  as  a  means  of  ascertaining 
the  number  of  ions  which  are  present  in  the  fluid.     We  could 
speak  of  an  "  ionic  concentration  "  and  then  endeavour  to  make 
out  a  relation  between  the  actual  figure  representing  the  electro- 
conductivity  and   a  figure  representing  successively  increasing 
degrees  of  ionic  concentration.     As  a  matter  of  fact,  this  is,  how- 
ever, not  possible,  and  we  have  to  arrive  at  our  deductions  in  a 
roundabout   way,  by  ascertaining   the   conductivity   }x)s.sessed 
by  different  strengths  of  solutions  of  given  salts,  such  as  sodium 
chloride  and  sodium  carbonate.     If  we  determine  the  conduc- 
tivity of  a  i-per-cent.  solution  of  sodium  chloride  and  that  of 
15,  2,  25,  3,  3'5,  40,  45,  50,  etc.,  per  cent,  solutions  of  NaCl, 
and  then  compare  that  of  the  fluid  which  is  being  examined, 
so  as  to  find  with  which  strength  of  XaCl  that  fluid  agrees  in 
conductivity,  we   can    saj'    that    the    fluid   contains   a   certain 
concentration    of    salts,    expressed    as    NaCl.       If    the    chief 
constituent  of   the   fluid   be   NaCl,    we   shall   not    be    making 
a  serious  error,  other  things  being  equal,  in  comparing  a  fluid 
at  one  time  with  a  similar  fluid  at  another.     It  is  a  method 
such  as  this  which  has  been  employed  throughout   the  present 
work. 

But  there  is  another  use  for  the  conductivity  method.  Supjwse 
that  a  certain  solution  of  sodium  chloride  has  a  conductivity 
which  can  be  represented  by  the  number  185,  and  suppose  that 
we  now  dilute  this  same  fluid  of  unknown  strength  a  definite 
number  of  times.  We  shall  find  that  the  conductivity  may  have 
risen  to  196,  say.     If  the  fluid  be  still  further  diluted,  we  shall 

of  fluid  weighs  1,000  ^  grams  ;  it  the  substance  in  sohition  weigh  s,  then  the 
water  in  a  htreof  fluid  is  1,000  g-5grams.   The  osmotic  concentration,  if  given 

in  terms  bv  volume,  would  be     '        ^      tc>o  little.     Of  course,  if  s  is  very 
■^  1 ,  nnn 

little,  this  fraction  is  practically  negligible. 


!>?"IHk    .. 


kl 


98 


STUDIES   IN   I'UNCTLRE-FLUIDS 


find  ultimately  that  we  come  to  a  iwint  at  which,  no  matter  what 
the  dilution  may  he,  we  do  not  alter  the  conductivity  any  further. 
The  figure  remains  constant.  This  means  that  the  sodmm 
chloride  present  has  been  as  completely  ionised  as  i^ssible.  It 
the  figure  representing  the  conductivity  be  now  209,  we  can 
ascertain  the  degree  of  dissociation  of  the  NaCl  in  the  ongmal 
fluid  from  the  simjile  relation  : 


Coiicliirlivitv  of  ori);inal  fluid     ^  185 
CoiiilULtivity  at  inliiiitL  dilution       209 


=  0-89. 


Which  means  that  of  every  gram-molecule  present  at  first,  o'Sg 
part  of  this  molecule  was  in  a  dissociated  state. 

It  IS  obvious  that  we  are  arriving  at  the  same  result  as  we 
were  domg  with  cryoscopy,  when  we  were  calculating  the  lomsed 
portion  of  a  fluid  on  page  (,0.  with  the  excep..m  that  bv  the 
conductivity  method  we  arrive  at  our  result  in  a  very  short  space 
of  time.  All  that  it  is  necessary  to  do  is  to  ascertain  by  experimen 
the  conductivity  of  the  original  fluid  at  a  given  temperature,  and 
then  dilute  the  fluid,  say,  four  times.  Multiply  the  new  con- 
ductivity figure  by  4,  and  this  gives  the  conductivity  of  the  fluid 
as  it  should  have  been  when  undiluted.  Repeat  this  for  ever- 
increasing  dilutions  until  the  final  conductivity  remains  the  same 
or  attains  a  maximum. 

The  following  example  will  explain  this  procedure : 

TABLE    Xll 
TiiE  Dissociation  of  a  Pleural  Fluid 


Distribution  of  I'leural 
Fluid. 


Observed  Conductivity. 


Conductivity  x  times  diluted. 


I'ndiluted. 

84.? 

2 

537 

4 

296 

8 

173-3 

16 

942 

32 

45-< 

64 

28-33 

128 

1443 

2S6 

901 

5>2 

4  35« 

843 

1074 
1184 

13864 
1507-2 

1443-2 

I829I 
18470 
22965 
2227  7 


The  last  values  for  observed  conductivity,  x  times  diluted, 


PHYSICO-CHEMICAL   EXAMINATION 


99 


show  that  the  maximum   has  been  attained,  so  that  we  have 
approximately  arrived  at  "  infinite  "  dilution. 

The  degree  of  dissociation  is  therefore       .    =  o^S. 

It  is  needful  here  to  pause  to  consider  how  far  the  deductions 
described  are  really  justified.  We  have  taken  a  sjxicinien  of 
pleural  fluid  and  diluted  it  with  water,  and  estimated  the  electro- 
conductivity  of  the  successive  dilutions.  Now,  pleural  fluid  often 
consists  largely  *— by  volume,  if  not  by  weight— of  albumen, 
which  is  a  viscid  substance,  besides  being  a  non-conductor  of 
electricity.  To  put  it  in  other  words,  we  ha%-e  in  serum  a  mixture 
of  electrolytes  and  non-electrolytes.  Xow,  a  non-electrolyte  is 
a  substance  which  has  the  power  already  referred  to  of  inhibiting 
the  dissociation  of  salts  with  which  it  may  he  associated.  The 
albumen  in  the  fluid  will  therefore  interfere  wifi  the  conductivity, 
and  if  the  fluid  he  diluted  a  littl-  reflection  wi  show  that  although 
the  non-electrolyte  serum-albumen  is  l>eing  diluted,  yet  it  does 
not  dissociate,  while  the  salts  (electrolytes)  present  are  dissociating 
in  the  water.  The  presence  of  the  still  undissociated  molecules 
will  exercise  more  retardation  than  ever  on  the  dissociated  mole- 
cules—number for  numlier.  That  is  to  say,  the  conductivity 
will  lie  ever  less  than  it  should  be,  and  the  degree  of  dissociation 
will  work  out  less  than  it  should  be.  The  figure  038  in  the  above 
example  would  then  be  much  too  small. 

We  are  able  to  correct  this  error,  by  the  aid  of  researches 
by  Bugarsky  and  Tangl,  who  found  that  for  every  degree 
per  cent,  of  albumen  the  conductivity  of  the  electrolytes  was 
diminished  by  25  per  cent.  If  we  make  the  needful  correction 
for  the  original  conductivity  and  divide  that  by  the  conductivity 
of  serum  at  infinite  dilution,  we  shall  get  a  degree  of  dissociation 
of  041.  But  we  have  not  corrected  for  the  interference  of  the 
diluted  serum  on  the  diluted  electrolytes.  The  needful  fornmla; 
for  this  are  not  to  be  had,  so  that  in  this  case  we  have  to  content 
ourselves  with  a  statement  that  the  degree  of  dissociaticn  of 
pleural  fluid  lies  between  038  and  041.     This  is  unsatisfactory.+ 

»  Depending  on  the  variety  of  the  effusion  (whether  exudate  or  trans- 
udate). 

t  Fortunatelv,  however,  the  value  of  a  knowledge  of  the  degree  of 
dis.sociation  of  various  !>ody  fluids  r-  r,ot  appan-nfly  of  much  importance, 
and  probably  depends  entirely  on  the  comjiosition  (relations  between  salts 


lOO 


STUDIKS   IN    rUNXTURE- FLUIDS 


Not  only  is  there  the  interfering  influence  of  non-electrolytes 
on  electrolytes  present  in  the  case  of  serum,  but  there  is  also 
the  interference  resulting  from  friction  between  the  ions.  The 
friction  is  much  greater  when  the  serum  is  undiluted  than  when 
it  is  diluted,  because  there  is  so  much  albumen  present.  The 
very  dilute  serum  exhibits  no  noteworthy  degree  of  ionic  friction. 
However,  we  may  sum  up  the  retarding  influence  as  that  due  to 
the  albumen  as  a  whole,  and  by  making  use  of  the  following 
formula, 

original  conHiictivitv  x  ICO 
Corrected  conductivity  =  ,oo„  ip^^^rccntage  ol  albumen  x  i  5). 

cori>  ct  for  all  errors  together. 

But  there  is  one  more  point  to  consider  in  connection  with 
this  part  of  the  subject,  and  that  is  as  regards  the  actual  electro- 
lytes   i^esent.     Is   it    justifiable    to    express    the  concentration 
of  electrolytes  in  terms  of  NaCl,  or  should  it  be  expressed  in 
terms  of  any  other  body  ?     This  question  must  be  answered  in 
favour  of  the  latter  in  some  cases,  and  of  the  former  in  others. 
The  following  figures  will  illustrate  this  conclusion  : 
A  given  pleural  fluid  contained  oo()2  gram-molecule  i^r  litre 
of  NaCl.     Its  conductivity  *  was  1068,  which,  for  the  tempera- 
ture, is  equivalent  to  that  of  a  solution  of  NaCl  of  0123  gram- 
equivalent  per  litre.     The  difference,  0061,  gives  the  concentra- 
tion of  the  achlorides  in  terms  of  NaCl.     The  ratio  of  chlorides 
to  achlorides  is  then  0062  :  0061  —  1016.     This  is  a  simple 
calculation. 

and  albunun),  so  that  \vc  get  no  further  by  this  method  of  study  than  by 
an  onlinarv  chemical  examination. 

Thus,  tile  lollowins  values  have  been  obtained  in  the  case  of  bile: 


Fluid. 


Number  of  Specimen. 


Degree  of  Dissociation. 


Bile 


I 

3 

3 

4 

\ 

7 


023 

034 
048 
051 
054 
041 
0-25 


•  Throughout  this  account  "  conductivity  "  means  "  specific  conduc- 
tivity," and  is  expressed  in  terms  of  lo"*. 


PlIYSICO-CflEMICAL    EXAMINATION 


lOI 


The  other  method  gave  these  results  : 

The  chlorides  amounted  to  0062  gram-molecule  per  litre. 
The  degree  of  dissociation  of  this  (calculated  by  Arrhenius' 
formula)  is  oSGi.  The  number  of  molecules  plus  ions  (above 
formula)  is  01 153.  The  conductivity  of  such  a  strength  of  NaCl 
subtracted  from  that  of  the  fluid  gave  a  conductivity  which  is 
possessed  by  a  solution  of  NaoCOj  containing  0062  gram-molecule 
\yeT  litre,  with  a  degree  of  dissociation  of  0570,  and  01342 
molecules  plus  ions  per  litre. 

The  ratio  NaCl  :  Na.COj  is  now  116. 

This  calculation  is  obviously  much  more  prolonged.* 

In  the  case  of  certain  transudations,  and  in  the  case  of  urine, 
the  preponderant  electrolyte  present  is  undoubtedly  sodium 
chloride,  but  in  the  case  of  exudations  sodium  chloride  does  not 
occupy  such  a  conspicuous  position,  and  sodium  carbonate  takes 
its  place  to  a  certain  extent.  In  blood-serum  the  sodium  and 
the  chlorine  are  the  twc  ost  abundant  elements,  the  jiotassium, 
calcium,  phosphates,  and  carbonates  are  the  least  abundant,  as 
shown  by  the  following  analysis  of  pus-serum  by  Hammarsten  : 


NaCl 

Na,SO,  ... 
Na.,HPO,... 
Na.CO,  ... 
Ca;(PO.),... 
Mg,(PO,), 
PO,  (in  excess) 


539% 

031 

0-46 

«  13 
0-31 

0-I2 
005 


Chlorides     5'39'; 

Carbonates  ...  ...  1"I3 

Sulphates 031 

Total  phosphates  ...  094 


This  shows  the  prejwnderance  of  carbonates  over  j)hosphates 
and  sulphates.  It  must  be  admitted  that  this  is  not  invariable, 
but  it  has  been  found  that  even  if  the  phosphates  be  in  excess 
and  the  mode  01  expression  of  achlorides  be  altered  accordingly, 
the  ratio  still  remains  similar.  It  is  obvious  that  the  only  way  of 
avoiding  errors  at  all  would  be  by  complete  chemical  analysis. 
The  present  method  is  an  attempt  to  obtain  useful  results  by  the 
simple  method  of  conductivity  determination. 

The  method  of  study  of  the  particular  fluid  would  therefore 
consist  in  the  following  observations  and  calculations.  In  the 
first   place,  we  a  certain   the  freezing-point  depression,  which, 

•  An  error  may  lie  in  these  calculations  in  the  values  used  for  the  con- 
ductivity ot  NaCl  ami  Na.CO,  solutions,  ^vhlch  have  been  r-tirt-.^Ued  in 
watery  solution,  whereas  they  occur  in  alhuminous  solution  in  the  body. 
The  degree  of  dissociation  is  vastly  different. 


lo: 


STUnilS   IN    I'UNCTURF-FLUIDS 


when  divided  by  i  85,  will  give  the  total  number  of  molecules  plus 
ions,  the  osmotic  concentrotion. 

Secondly,  we  ascertain  the  clectroconductivity  at  a  given 
temperature. 

Thirdly,  we  ascertain  the  amount  of  albumen  present,  if  any. 
Thin  the  value  for  the  conductivity  can  be  corrected  by  the  use 
of  fornuila  on  p.  100.  There  are  now  two  courses  oix>n— one  can 
ascertain  wh.at  strength  of  sodmm  chloride  has  the  same  con- 
ductivity by  calculation,  or  one  can  ascertain  the  actual  concen- 
tration of  the  chlorides  in  this  fluid  by  means  of  chei  lical  analysis 
and  ascertain  how  much  of  the  conductivity  (or  of  the  freezing- 
point  depression)  is  represented  by  them.  We  shall  then  have 
the  concentration  of  the  electrolytes  as  a  whole  expressed  in  terms 
of  yaCl,  and  the  concentration  of  the  chlorides  alone,  the 
difteren'c  between  the  two  giving  us  the  concentration  of  the 
"  achloridt;  "  electrolytes— that  is,  the  electrolytes  other  than 
chlorides,  expressed,  however,  as  if  they  were  NaCl. 

Or,  again,  we  can  express  the  concentration  of  achlorides  in 
l.-rms  of  carbomiks,  by  ascertaining  what  strength  of  solution  of 
Na.COa  has  the  same  conductivity  as  "  total  conductivity- 
conductivity  of  the  given  concentration  of  NaCl." 

L.  order  to  ascertain  the  concentration  of  carbonate  according 
to  a  given  conductivity  it  is  necessary  to  ascertain  the  conduc- 
tivity of  a  series  of  solutions  of  sodium  carbonate  of  known 
strength.  This  is  best  performed  in  a  number  of  specimens  pre- 
]iared  by  oneself,  the  intermediate  values  being  either  obtained 
by  Lagrange's  interpolation  formula  : 


>■«  = 


n)  (X  -a)  (X  -c)  ■■■  (X  -n)^.^  ^ 

(a~^"br(a -c)  ...  (a  -  n)^*       (b  -  a)  (b  -  c  ...  (b  -  n) 


(X  -  b)  (x  -  c)  ...  (X 


where  y^  is  the  lowest  value  for  omdiicthily.  v,  the  ne.xt  value  (deter- 
mined by  experiment  in  each  case),  and  y,  the  value  for  conductivity  at 
any  strength  of  N'a.CO,  desired,  a  is  the  concentration  of  Na.CO^  of 
conductivity  y^.  h  that  of  y,.  and  so  on  ;  n  is  the  concentration  of  the 
strongest  .solution  whose  conductivity  one  has  determined,  and  -v  is  the 
strength  of  the  solution  whose  conductivity  one  seeks, 

or  by  drawing  a  curve,  on  which  the  intermediate  values  can  be 
read  off.*  It  is  important,  as  will  be  shown  presently,  that  all 
the  observations  be  made  at  one  temperature,  say  18X. 

*  While  the  graphic  method  is  the  simpler,  it  is  also  the  less  accurate. 


PHYSICO-CHEMICAL   EXAMINATION 


«03 


Not  only  is  it  desirable  to  know  the  concentration  of  the 
carbonates  and  chlorides  in  a  given  solution,  but  it  is  desirable 
to  know  tlu  number  of  molecules  plus  iom  of  each  class  o/ 
electrolyte  per  Hire  of  fluid.  This  demands  a  more  lengthy 
calculation,  which  will  be  found  to  have  been  adopted  m  the 
series  of  analyses  on  puncture-fluids  described  in  the  section  on 
differential  diagnosis  (IV.)- 

The  method  of  calculation  is  as  follows  : 
Starting  with  the  jiercentage  of  chlorides   in  the  fluid,  we 
ascertain  the    same  value   in  terms  of   "  concentration  "  ;    i.e. 
gram-molecules  per  litre.     From  this  value  the  degree  of  disso- 
ciation is  ascertained  from  the  formula  j--^  j  ^  where  A  is  the 
equivalent  conductivity  of  the  solution  of  NaCl.  and  1,.„  1,.  the 
rate  of  migration  of  the  ions  Na  and  CI  at  infinite  dilution. 
Now  K..  +  1.  ^    44-4  +  65-9  =  "0-3.     The  equivalent  conduc- 
tivity  can  be  ascertained  for  any  strength  of  solution  at  18    C. 
from  the  tables  given  in  the  Apjicndix. 

Having  ascertained  the  degree  of  dissociation,  its  value  is 
put  into  the  formula  of  Arrhenius  :  (i  -I-  «)  gram-equiv. 

The  result  gives  the  number  of  molecules  plus  ions  m  the  given 
concentration  of  NaCl. 

The   following  formula  will   be   found   to    give    the    result 
desired  without  any  further  trouble  : 


Mols.  +  ions 


I   + 


(■'•-je't.  Ill"  :■"')> 

^  1 10  3 


where  a  =  gm.-equiv.  solution  of  NaCl  in  question 

Q   ^  ,^  „  in  Kohlrauscb's  table  less  strong  than  a. 

"  "  '  ,  ,.      itronger  than  a. 


-0  ■ 
t,  = 


Y    =  equivalent  conductivity  of  solution  C,,. 

r 


A,  = 


Having  subtracted  the  value  for  the  conductivity  of  the 
fluid  being  examined  from  that  for  the  given  strength  of  chlorides 
(estimated  by  analysis),  the  difference  gives  the  conductivity  of 
the  achloride  electrolytes.  Reading  off  either  in  one's  diagram, 
o-  in  the  list  of  conductivities  which  one  has  prepared  from  a 
series  of  strengths  of  Na,CO„  we  ascertain  to  what  concentration 
of  NajCOj  this  conductivity  corresponds,  so  that  it  is  now  possible 


I04 


STUDIES  IN   rUNCTURE-FLUIDS 


to  calculate  the  numl)cr  of  molecules  and  ions  in  this  strength 
of  NajjCO:,.     Proceeding  in  the  same  way  we  get  this  formula  : 


Mols.  +  i<j|is  NaXOj  =  1  +  2 


where 


\        1134        / 


<J    =  gratn.-eqiiiv.  solution  of  Na.^CO,  in  question. 

Cg  =         „  „  „         in  Kohlrausch\  table  less  strong  than  a. 

^  I  —         II  M  II  ,1  ,,       stronger  than  a. 

Aq  =  equiv.  conductivity  of  solution  C,,. 

A|  =       I,  II  ,,  C|. 

Finally,  number  of  molecules  plus  ions  of  chlorides  plus 
number  of  molecules  i)lus  ions  of  carbonates  represents  the  total 
number  of  molecules  plus  ions  in  each  litre  of  the  fluid  under 
consideration  ;  i.e.  Qi,t,.  and  this  value  subtracted  from  the 
osmotic  concentration  of  the  fluid  gives  the  concentration  of 
the  non-electrolytes  (C„„„,. ,,.,,). 

The  osmotic  pressure  of  the  non-electrolytes  is  given  by  the 
formula : 


Total  freezing-point  depression 


f-pt.  dep.  of  sol"  of  .NaCl\ 
of  same  cone,  as  lluid   / 


12-05 


where  NaCl  is  assumed  to  be  the  only  electrolyte. 

We  have  now  arrived  at  the  following  facts :  A  given  fluid 
possesses  a  certain  osmotic  concentration  (Co),  which  is  made 
up  of 

C,„  the  concentration  of  non-electrolyt-3. 

Cetect  the  total  concentration  of  electrolytes :  that  is, 

C,i,ior.  the  concentration  of  chloride  electrolytes  plus 

C.tiiior.  the  concentration  of  achloiide  electrolytes. 

The  first  is  deduced  from  the  cryoscopic  determination,  the 
second  by  direct  analysis,  and  the  last  two  by  the  aid  of  a  con- 
ductivity determination. 

There  are  yet  two  considerations  which  must  be  borne  in 
mind  in  order  to  estimate  the  correctness  of  this  process  of 
calculation  with  justness. 

(i)  When  we  are  dealing  with  an  albuminous  fluid  with  a 
view  to  ascertaining  the  quantity  of  sodium  chloride  with 
ahsnlute  accuracy,  we  are  in  two  dilemm.is  which  do  not  seem 
to  have  been  realised  in  their  full  extent.  There  is  firstly  the 
question,  Does  all  the  chlorine  exist  in  combination  with  sodium 


I'llYSICO-CHEMICAL    EXAMINATION 


105 


only  ?  and  secondly,  Can  one  separate  albumen  completely  from 
a  fluid  without  altering  the  amount  of  sodium  chloride  which 
remains  in  the  de-albuminised  fluid  ?  A  candid  opinion  will 
certainly  answer  l)oth  these  questions  in  the  negative,  though  it 
would  l)e  admitted  that  the  amount  of  chlorine  which  is  not  united 
with  Na.  but  with  some  other  metal,  is  very  insignificant,  and  not 
likely  to  lead  to  any  error  that  is  worthy  of  consideration  in  what 
is,  after  all,  only  a  rough  method  of  analysis  (siK-aking,  that  is 
to  say,  of  electroconductivity).  The  methods  which  may  Ix; 
adopted  for  the  estimation  of  chlorides  in  puncture-fluids  have 
already  been  dealt  with  in  Section  I.,  and  it  was  there  jxjinted 
out  how  necessary  it  is  to  decide  how  much  of  the  CI  is  free 
and  how  much  in  combination  wifh  the  albumen,  and  the  advan- 
tage of  simplicity  which  an  estimation  of  chlorine  titrimetrically 
after  removal  of  the  albumen  by  boiling  has. 

(2)  The  effect  of  variations  of  temperature  on  the  conductivity 
of  the  fluids  examined.— As  would  be  exjxicted,  the  warmer  the 
fluid,  the  better  will  be  its  conductivity.  This  is  due  to  the 
mcreas^d  rate  of  migration  of  the  ions  with  the  increase  in  the 
temperature. 

In  practice,  the  author  has  found  it  most  convenient  in  the 
end  to  make  all  determinations  of  every  kind  at  a  temperature 
of  18°  C,  which  is  the  temj^rature  at  which  the  determinations 
of  conductivities  of  various  substances  by  Kohlrausch,  Holborn, 
etc.,  have  been  made.  The  advantage  lies  in  the  fact  that  one 
has  now  no  correction  to  make  for  temix?rature  variations.  It  is 
true  that  there  are  correction  tables  to  be  had,  by  which  one  can 
calculate  the  conductivities  of  salt  solutions  at,  say,  37^,  or  body 
heat,  but  the  formula  do  not  give  quite  accurate  results,  and  are 
only  really  approximate. 

However,  as  there  is  always  the  risk  that  one  may  not  be  able 
to  make  an  observation  exactly  at  18  '  C,  either  from  the  thermo- 
stat being  out  of  gear  (changing  the  water,  for  instance),  or  from 
a  desire  to  make  an  observation  at  a  moment's  notice,  it  becomes 
of  more  than  mere  academic  inteicst  to  know  how  the  error  may 
be  corrected. 

As  there  is  a  rise  of  conductivity  for  each  degree  rise  of  tempera- 
ture, one  might  expert  that  there  were  some  m.athernatical 
relation  between  the  two.  For  instance,  if  the  conductivity  be 
known  at  18=  and  also  at  25  and  30  and  37°  C,  one  should  be  able 


I06 


STUniFS   IN    I'UNCTURE-FLUirS 


to  work  out  the  intermediate  values  with  tolerable  accuracy  by 
aid  of  the  differential  calculus.  This  is  so.  Hut  this  involves 
actual  determinations  at  each  of  these  tem|)eratures  for  that 
particular  strength  of  solution.  It  would  1)C  necessary  to  do  the 
same  for  every  variation  in  strength  of  solution,  a  procedure  which 
would  become  most  irksome.  It  is  true  that  one  might  proceed 
on  similar  lines,  and  deduce  a  formula  by  which  one  could  calcu- 
late the  conductivity  of  successively  increasing  strengths  of  salt 
solution,  hut  then  we  should  be  having  two  variables,  or  two 
series  of  only  approximate  values,  a  condition  wl"ch  is  undesir- 
able. 

The  increase  in  conductivity  which  would  occur  with  each 
degree  rise  in  temiwrature  has  been  called  the  temixjrature 
cooiricient,  and  has  been  worked  out  for  various  substances. 
The  temiK-rature  coefficient  is  calculated  as  follows : 
For  a  difference  in  temjierature  of  t...  —  t...,  where  to  is  the 
higher  temiwrature,  the  conductivity  is  ko-k,,  so  that  for 
I  degree  the  conductivity  would  alter  by 


k.. 
t.. 


■k, 


The  relation  between  the  rise  per  degree  to  the  total  conduc- 
tivity, i.e.  the  temperature-coefficient,  will  therefore  be: 


k,-k, 


k.  -  k, 

t.,  —  t| 


I       k.  —  k 

i.e.  coefficient  (c)  =  —  x  -= — -- 

or,  k.  =  k,(l  +  ct), 

where  t  is  the  number  of  degrees  rise  of  temjx^rature. 

If,  therefore,  one's  observation  be  made  at  22^  C.  instead  of 
at  18°,  one  substitutes  for  the  conductivity  found  the  result 
of  multiplying  this  conductivity  by  (i  +  difference  in  tem- 
perature), viz.,  4  multiplied  by  the  coefficient,  which  might 
be   020. 

The  formula  is  more  likely  to  hold  good  the  less  the  rise  of 
temperature.  That  is  to  say,  the  correction  in  the  cited  example 
will  be  more  correct  than  if  the  higher  temix;rature  had  been 

37 '  C. 

From  observations  by  Bugarsky  ?nd  fangl  we  may  correct 


PHYSICO-CllEMIl  AL   EX  AMINATK  (N 


107 


for  tinijwrature  in  the  exjicriments  with  puncture-fluids  by  the 
aid  simply  of  the  following  formula : 

.  k,    K  (t  -  iS)   «  i-jl 

where  t  is  the  higher  temiKTature,  k,  is  the  conductivity  ascer- 
tained by  exixTiment  at  this  higher  temperature. 

We  are  now  in  a  |>osition  to  discuss  the  effet  I  of  mixture  of 
electrolytes  and  non-electrolytes  on  the  freezing-iH)iiit  depression 
and  on  the  conductivity,  esix'cially  in  cases  in  which  van't  Hoft's 
law  does  not  hold. 

The  simple  conceptions  already  detailed  do  not  hoKl  for  a 
wide  range  of  dilutions,  but  the  o-imotic  pressure  will  show  de- 
viations from  the  law  as  one  passes  to  high  or  to  weak  dilutions. 
A  solution  of  cane  sugar  will  show  a  more  rapid  increase  of  osmotic 
pressure  on  dilution  than  woulil  be  the  case  if  the  simple  law 
held  good.  In  the  case  of  electrolytes  the  deviation  is  even 
more  decided. 

This  question  is  worthy  of  consideration. 

The  interaction  between  them  may  take  three  forms:  (i) 
inhibition  of  dissociation  of  electrolytes  ;  (2)  chemical  interaction 
leading  to  the  formation  of  a  numlx^r  of  larger  and  more  complex 
molecules  ;  (3)  polymerisation.  It  has  been  found  that  the 
latter  does  not  occur. 

This  question  has  been  carefully  gone  into  by  Ernst  Tezner, 
and  he  made  up  accurately  weighed  solutions  of  mixtures  of  this 
kind,  in  order  to  discover,  if  iKjssible,  whether  there  were  any 
relation  capable  of  mathematical  expression.  The  results  ob- 
tained showed  that  when  the  concentration  in  watery  solution 
is  increased  the  osmotic  pressure  and  other  colloid  properties 
increase  much  more  rapidly  than  van't  Hoff's  law  would  have. 
This  fact  is  noticeable  in  e^•'?n  very  dilute  solutions  (more  than 

— )       If  there  are  several  different  substances  present  in   the 

solution,  the  total  depression  of  freezing-point  is  less  than  the 
sum  of  the  components. 

Starting  with  van't  Hoff's  formula  : 

*  (k   +   k|)  =  osmotic  concentration  of  the  dissolved  substances,  W  = 
latent  heat  of  fusion,  T  =    absolute  temperature,  R  =  constant. 


11 


lOS 


STI'IUKS   IN    I'l  NrliKh-FHIDS 


where  \V  ami  T  loinain  constant  whether  the  siiJwtanres  are 
mixed  or  wlutlur  tluy  remain  separate,  Tezner's  exiH'riments 
show  that  — 

l<r-     ,,        ,    ,   y    KT'    ,,    .      HI 


(k 


loo  W  \i(X)  VV  IO.J  W 

or  k  +  k,       k'  •»•  k'. 

By  mixiiiK'  toiiiiMjnents,  the  osmotic  concentration  becomes 
iliminished. 

By  it'lihng  non-electrolytes,  further,  the  friction  fx'tween  the 
io"  .creiLsed,  and  their  rate  of  migration  altered;    there  is 

increased  viscosity.  These  effects  are  manifest  in  the  change 
of  the  electroconductivity  of  the  solution.  The  equivalent 
conductivity  .V  comes  to  he  diminished  U-cause  of  the  change 
in  the  vi.sct)sity  V  and  in  the  iliminution  of  <lissociation  D. 

Since  the  chang*-  in  the  osmotic  pressure  is  a  simple  function 
of  dD  this  equation  will  enable  l(d\')  to  l)e  calculated  as  increase 
in  viscosity  (not  an  acHial  change  of  viscosit^'). 

The  degree  of  dissociation  is  the  exjiression  of  the  state  of 
equilibrium  which  results  from  the  force  of  separation  of  the  ions 
acting  against  or  with  the  force  of  electrostatic  attraction  between 
opjMJsitely  chargetl  ions  ;  and  the  degree  of  dissociation  is  an 
expression  of  the  dissociating  power  of  the  electrolytes.  The 
force  of  electrostatic  attraction  prevents  new  ion-combinations 
from  forming,  and  may  Ix;  e.\|)ressed  by  the  dielectricity-constant, 
a  constant  which  is  diminished  the  greater  the  concentration  of 
the  non-electrolyte. 

Tezner  a^crilies  the  entire  effect  of  adding  a  non-electrolyte 
to  an  electrolyte  to  diminution  of  the  ionisation  of  the  fluid. 

The  introduction  of  several  new  considerations  into  the  alwve 
arguments  shows,  however,  how  complex  the  problem  is  with 
which  we  have  to  deal  when  we  wish  to  form  some  conception 
of  the  actual  ionic  or  other  constitution  of  such  a  fluid  as  a 
puncture-fluid. 

We  are  indebted  to  Arrhenius  for  turtlier  considerations  about  ionisa- 
tion in  mi.\tures  of  electrolytes  from  thepoint  ol  viewof  electroconductivity. 
He  correlates  the  following  :  (i)  the  degree  of  dissociation  in  a  mixture  of 
'.'lectrolytes  is  repri>sented  by  th''  formula  : 

Cone.  X  A  =  const,  (cone.  X)', 
— X  and  A  being  dilYerent  electrolytes.     {2)  In  a  mi.\ture  of  salts,  the 


IIIVS!C(M  HKMH  AL   KXAMINATIDN 


109 


'.ilts  arc  «lisH<Ki.ilril  to  luarlv  the  s.iiiH'  iWmt  a-.  Ilir  iiiolnular  roimn- 
tration.  aii<l  tlif  fraction  winch  ritiiainH  iimli'.f.ociatfil  is  proiMirtiotial  ti» 
\Uv  (mxliitt  of  lit!  valtiirus  ol  tlu'  two  loii-.  ;  (1)  "'  tlu'  niiiulH  r  of  ions 
p.  r  ciil'ic  cintimctre  !>«•  the  Name  in  tlu'  two  dilutions  (i-oliy<lric),  tlif 
iti^ri'i-  of  tiiisociation  will  not  altrr. 

(one.  X  A  —  intnt.  »  cnnc.  X  *  lonc.  A. 

If  ii  l)c  till'  comluctivity  wliuli  tlii'  solution  wouUI  liavr  if  only  oni- 
Mihttancc  wiTf  iliHsolvi'd,  ami  .1,.  tliat  which  it  would  havf  if  tlir  otii.  r  only 
wire  .lisM)l\i<l.  thin  on  mixinK  thf  two  tin-  water  may  l.f  su|)|h)miI  to  In- 
ilnidtil  into  tw<i  parts,  tach  luniK  isohytlric.  If  i.  >,  '"'  the  rcs|Mctivc 
\oluiius  111  the  Milutions 

i-oniliiitivily  ofmixliui-  «  (v  +  i\)  —  oc  ♦■  o,  r,  ; 

(4)  till-  '  lon  btwitn  the  ions  has  also  to  1h-  consiilereil,  a  correction 
lieinsj  espi.ially  necessary  in  the  case  of  soliiiiim-.  alwiM  o  111.  ami  may 
attain  1  to  }  )»  rcent.  even  at  the;  decree  of  dilution.  TaUinK  into  account 
this  factor,  .Srrlunuis  suKRests  the  formula  : 

i-nnftt.  (cnnc,  of  ions  X  *)  fconi-.  of  inns  A") 

Cone,  of  XA  =■       /        ,  ..         »,  .^       v   .  ^    \      ^   a      "^;  T 

V- total  coix.  of  ions  X  +  +  A,  '+•...  +  A     +  A,     +....) 

X.    \.  <tc.   representing  different  salts. 

Many  attempts  havo  Ix'on  inadi'  to  ilravv  sotnc  relation 
iK'tween  the  freezitig-point  depression  of  a  rtiiitl  and  its  specific 
gravity.  Fuchs  considered  that  the  specific  gravity  of  urine 
tnultiplied  by  0075  will  give  the  freezing-jwint  depression.  Other 
factors  have  Ix^en  devised  by  different  observers.  If,  however, 
we  reflect  upon  how  many  conditions  the  froezing-|)oint  depres- 
ii  1!  u  '    nds,  we  sh :«11  at  once  see  that  any  factor  of  this  kind  must 

needs  fail. 

Th>!    following    figures    from    cases    in    the    Leeds    Genera) 
Infirmary  will  show  the  incorrectness  of  such  formuUe : 


TABl-K  XIII 


Specific  Gi«vity, 


Freezing-point  observed. 


Freezing  p.iint  ulcululed  from 
Ifif  ispecilic  tiravity. 


1024 

I  017 
1032 

I  on 
1 01 5 
1014 
roio 

I  022 
1029 


-  -  ■ ,- 



1-459                  i 

i-8o 

roJ5 

127 

rqio                 1 

238 

aoo6                 1 

a-47 

1061 

1126 

0990 

1047 

1  002 

0750 

0919 

mn 

135* 

.625 

1775 

2161 

I  10 


STUDII-S    IN    I'UNCTURK-KI.LIDS 


-,  I 


In  the  case  of  inuictino-fluids  the  calculated  results  arc  hojx?- 
lessly  incorrect. 

Wo  now  come  to  the  mcllwds  of  hcrjornting  cryoscopy  and 
(Icdroanhliictivity.  As  regaids  the  former,  the  widespread 
knowledge  of  the  methotl  rend(  rs  any  exact  account  superfluous, 
A;',  regards  the  second,  there  are  several  details  worthy  of  con- 
sideration, tspicially  from  the  standpoint  that  the  method  l>lays 
an  important  part  i:i  the  examination  of  puncture-fluids  as 
advocated  in  tiiis  work. 

1.  Cryoscopy.  —  S(iik';es  of  Eukok.  -The  first  possible 
source  of  error  lies  in  an  incorrectly  graduated  thermometer.  The 
calibre  of  the  tube  mav  not  be  absolutely  uniform,  so  that  each 
ilegree  of  the  scale  mav  hul  luive  the  same  value.  This  error  can 
be  allowed  for  liy  tl  <  alinary  methods  of  calibration.  The 
construction  of  liie  w  •'.ir  may  be  at  fatilt  :  the  sides  should 
slope  (juite  gradually  i  ;\\..rds  the  capillary. 

The  7,ero-point  mav  have  l)een  incorrectly  tletermined.  The 
best  way  of  ensuring  the  coirectness  of  this  is  to  make  several 
determinations  at  the  outset,  and  take  die  mean.  Subsequent 
extreme  care  in  hantUing  the  instrument,  with  occasional  controls 
of  the  zero  after  tlays  or  weeks,  according  to  the  frequency  of  its 
use,  will  sufhce.  It  is  essential  to  use  absolutely  pure  water 
(or  distilled  water  which  has  been  boiled  to  liberate  gases)  for 
the  j)uri)ose  of  fixing  the  zero-point.  It  is,  however,  best  to  use 
water  which  has  been  twice  distilled,  and  once  with  glacial  phos- 
phoric acid.  rel)oiled,  and  preserved  in  absolutely  scrupulously 
clean  (boiled  with  acid,  etc.)  Jena  glass  flasks. 

A  further  control  is  obtained  by  estimating  the  freezing-point 
of  a  i-per-cent.  solution  of  pure  sodium  chloride  in  distilled  water 
after  each  observation  of  a  fluid.  It  is  much  easier  to  obtain  the 
freezing-point  of  a  salt  solution  than  of  pure  water,  and  this  gives 
a  control  on  the  accuracy  of  the  instrument. 

The  next  source  of  error  is  undercooling,  because  the  more 
the  fluid  is  frozen  the  more  ice  separates  out.  and  the  more  con- 
centrated becomes  the  residual  salt  solution.  If  only  halt  a 
degree  of  undercooling  is  allowed,  then  only  i  bo  of  the 
bulk  of  the  fluid  has  separated  out  as  ice,  and  the  resulting  error 
is  negligible.  The  freezing-point  may  be  reached  by  this  time 
if  the  mixture  be  suddenly  energetically  stirred  as  soon  as  so 
low  a  temjierature  has  been  reached. 


PHYSICO-CHEMICAL   EXAMINATIO 


I  I  I 


The  error  which  may  arise  from  using  too  powerful  a  freezing- 
mixture  is  similar,  but  the  moans  of  avoiding  this  have  alioady 
been  explained.  The  temperature  of  the  freezing-mixture  should 
not  be  more  than  3  C.  below  that  of  the  freezing-point  of  the 
fluid  to  be  examined. 

Any  error  which  may  arise  from  the  fluid  not  being  cooled 
uniformly  is  avoided  by  careful  enclosure  of  the  apparatus  in 
cotton-wool  and  the  use  of  a  mechanical  stirring  device. 

Hamburger  recommends  that  at  each  determination  lie 
reading  of  the  thermometer  should  be  taken  for  a  i-jier-c  '•'.. 
solution  of  NaCl,*  and  also  foi  distilled  water.  If  this  be  do.io 
before  and  after  each  series  of  observations  one  can  control  the 
thermometer  itself,  as  it  occasionally  happx;ns  that  the  reailings 
vary  during  the  same  day,  either  from  variations  in  barometric 
pressure  or  from  changes  in  the  glass  following  exposure  to  coid. 

2.  The  Determination  of  Electroconductivity.—  The 
apparatus  which  is  necessary  for  determining  the  electrocon- 
ductivity of  a  fluid  is  usually  described  sufficiently  fully  in  text- 
books of  practical  physics.  The  following  account  will,  however, 
save  reference  to  such  works,  and  include  certain  practical  details 
■which  have  been  found  useful. 

The  following  diagram  will  indicate  the  various  parts  of  the 

apparatus,  t 

The  vessel  which  receives  the  fluid  to  be  examined  demands 
special  consideration.  It  consists  of  a  si)ecially  shaped  tulv, 
wide  above  and  narrow  below.  It  is  very  easily  cleaned.  As 
it  is  made  of  Jena  glass  there  is  no  risk  of  interaction  between 
glass  and  fluid  to  be  examined.  Every  time  it  is  used  it  is 
thoroughly  washed  out  with  distilled  water,  and  wiped  dry  with 
absorbent  non-medicated  cotton  wool.  Every  now  and  then  it 
should  be  cleaned  by  soaking  in  weak  nitric  acid  overnight.  If 
these  precautions  are  followed  there  is  no  need  for  errors  to  arise. 

•  To  prepare  a  i-per-cent.  solution  of  NaCl,  Hamburger  reconiinends 
that  10  grams  of  pure  NaCl  which  has  been  strongly  heated  in  a  porcelain 
basin,  to  drive  out  HCl  and  water,  Ix.-  dissolved  in  i  kilogram  of  pure 
distilled  water.  By  weighing  the  water  there  is  no  ri^k  ui  errors  from 
temperature  of  the  water  or  of  graduations  in  the  measure.  The  specific 
gravity  of  such  a  solution  is  rcx);^  at  o""  C  and  there  are  9970  grams 
per  litre,  or  1704  mol.  per  litre,  and  the  freezing-point  is-o'sS^'C.  By 
adding  a  ii'Me  thymol,  this  solution  will  keep  a  long  time. 

f  Ol-  I  from  Fritz  Kohler,  Iniversitats  Mechaniker,  Leipzig. 


112 


STUDIES   IN    I'UNCTL'Ki;-FLUIDS 


mercury.     This    has    been    found    most 
any     spilling    of    the    mercury     should 


The  adoption  of  this 
form  of  vessel  also 
avoids  any  considera- 
tion of  the  many 
varied  forms  of  vessel 
that  different  authors 
have  used  and  de- 
scribed, for  none  of 
them  are  so  readily 
cleaned  and  so  little 
liable  to  break. 

The  electrodes 
for  this  vessel  are 
arranged  as  in  the 
drawing  which  shows 
the  apparatus.  One 
electrode  passes 
through  the  other, 
and  they  are  formed 
of  strong  glass  tubing ; 
into  the  free  end  of 
each  the  electrode  is 
fused.  They  are  kept 
in  position  by  being 
fixed  into  an  ebonite 
disc  grooved  to  allow 
them  to  sit  firmly 
within  the  tube,  and 
be  absolutely  vertical 
in  it.  The  tubes  are 
three  jiarts  filled 
with  mercury,  and 
receive  thin  copj^er 
wires,  a  layer  o  f 
hard  paraffin  being 
added,  so  as  to 
completely  fill  the 
tube  above  the 
useful  for  preventing 
the     apparatus     be 


PHYSICO-CHEMK  AL   EXAMINATION 


"3 


accidentally  upset,  ami  the  copixr  wire  is  also  kept  firmly  in 
place.* 

The  Treatment  of  the  Electrodes.— It  is  neo  -;ary  to 
platinise  the  electrodes  thoroughly  before  they  cnn  be  us(  This 
increases  the  conducting  surface  very  greatly.  The  electrodes  are 
soaked  in  soda  solution  (placed  in  the  corresjwnding  vessel)  for 
a  few  hours,  and  then  rejieatedly  cleaned  with  water.  They  are 
now  placed  in  aqueous  platinum  tetrachloride  (the  usual  strength 
jiurchasable),  to  which  has  been  added  lead  acetate  to  the  extent 
of  0025  i^er  cent,  and  a  strong  current  passed  through.  Four 
Daniell  cells  will  serve  the  purpose.  The  current  flows  for  five 
minutes,  and  is  then  interrupted,  and  the  connections  altered  so 
as  to  reverse  the  current,  which  Hows  for  a  further  five  minutes. 
This  is  re}x>ated  till  both  electrodes  are  found  thickly  coated 
with  i)latinuni  black.  The  electrodes  are  now  left  in  distilled 
water  for  some  hours  before  use,  in  order  to  soak  out  impurities 
entangled  in  the  platinum  black. 

The  electrodes  are  to  be  kept  in  pure  water,  and  must  never 
come  in  contact  with  the  skin  or  be  allowed  to  dry  up.  In  the 
latter  case  they  would  have  to  be  cleaned  and  reblacked.  To 
remove  the  excess  of  water  before  dipping  the  electrodes  into  the 
fluid  to  be  examined,  all  that  is  necessary  is  to  hold  a  piece  of 
clean  filter-pa{)er  against  thorn,  when  they  become  almost  dry. 
They  are  then  rinsed  in  some  of  the  fluid  to  be  examined,  and 
subsequently  placed  in  the  vessel  containing  this  fluid. 

It  will  be  fovmd  essential  for  rapid  work  to  have  several  vessels, 
which  should  be  marked  in  successive  numbers  with  commercial 
hydrofluoric  acid.t 

As  regards  the  size  of  the  electrodes  it  is  only  necessary  to  say 
that  the  larger  the  electrode  the  more  accurate  the  results,  because 
otherwise  ]X)larisation  occurs,  esjjecially  with  a  low  resistance. 
The  result  is  shown  by  not  being  able  to  find  a  sjxjt  on  the  bridge 
where  the  sound  is  entirely  lost  in  the  telephone.  The  smaller 
the  electrode  the  more  careful  must  be  the  i)latinising, 

•  It  should  be  mentioned  that  in  case  of  breakage  it  is  best  to  send  the 
electrodes  and  vessel  straight  back  to  the  makers,  since  there  is  so  much 
ditliculty  in  obtainmg  hard  gla.ss  and  fusible  glass  of  exactly  the  same 
meltmg-point  as  each  other  and  as  the  platinum.  It  is,  however,  wise  to 
have  two  sets  of  electrodes  in  case  of  accident. 

t  It  is  also  convenient  to  etch  the  "  capacity  "  of  the  vessel  (see  below) 
on  the  glass. 

8 


114 


STUDIES   IN   rUNCTURE-FLUIDS 


The  UFC  of  fairly  large  electrodes  is  therefore  the  most  simple 
and  the  most  nccvnite. 

The  vessel  is  maintained  at  a  definite  temiwrature  correct  to 
TOO  degree  by  means  of  a  thermostat. 

This  thermostat  consists  of  an  enamelled  vessel  of  suitable  size 
covered  with  felt  and  raised  on  a  stand  sufficient  to  allow  a  small 
gas-jet  to  stand  beneath.  It  is  tilled  with  water  to  within  an  inch 
or  two  of  the  brim.  Into  the  water  dii>s  a  si^ecially  accurate  ther- 
mometer registering  to  bo- C .,  and  gradua  t  ed  into  tenths  of  a  degree. 

A  lens  will  allow  hundredths  to  be  read  off.  A  toluol  regulator  also 
dips  into  the  water.  This  form  of  regulator  is  the  most  sensitive 
and  satisfactory  in  all  ways.  A  mechanical  stirring  arrangement 
is  necessary  to  keep  all  parts  of  the  water  at  the  same  tem^ierature. 
The  ^Iethou  of  CARRViNe,  out  the  Determinations.— 
In  the  first  place  it  is  necessary  to  determine  the  resistance- 
capacity  ("  C  ")  of  the  vessel  into  which  the  fluid  is  placed. 
By  this  is  meant  the  resistance  presented  when  a  conductor  of 
conductivity  i  is  placed  in  the  vessel.  The  value  will  vary  with 
the  dimensions  of  the  vessel  used. 

The  standard  solution  of  known  conductivity  is  decinormal 
KCl,  and  the  vessel  receives  enough  to  well  cover  the  electrodes. 
The  vessel  is  placed  in  the  thermostat  at,  say,  i8'  C,  and  the 
connections  are  made  as  shown  in  the  figure,  the  induction-coil 
started,  and  a  resistance,  say  loo,  is  interposed  by  means  of  the 
box.  The  movable  }>oint  is  moved  alwut  till  there  is  silence  in 
the  telephone.  A  few  controls  may  be  made,  and  then  a  higher 
resistance  is  interjiosed,  and  another  reading  taken.  Again,  a 
third  resistance  is  used,  so  as  to  bring  the  reading  on  the  scale 
as  nearly  500  mm.  as  ixjssible,  since  most  accurate  results  are 
obtained  near  the  centre  of  the  bridge. 

The  capacity  is  equal  to  the  value  for  the  known  conductivity 
multiplied  by  the  mean  resistance  found  necessary  in  the  box. 
The  mean  resistance  is  obtained  thus  : 

Suppose  at  100  ohms  the  reading  is     49° 

and  at  120     ,,  „  '♦SS 

and  at    90     ,,  ,.  5*3 

Then  the  resistance  of  the  fluid  will  be : 

as  .V  :  100  : :  498  :  "coo  -  49^*  =  99  20 
as  .V  :  120  : :  453  :  '«»  -  453  =  99-384 
as  .r  :   90  : :  523  :  1000  -  523  =  98  636 

Mean     ...     990S6 
Capacity  =  conductivity  of  n/io  KCl  at  18=  (01119)  +  99 08  =  >io 


I'HYSK  O-CllKMICAL    l.XAMIN ATION 


I  I 


When  this  has  Ix'en  once  tleterminci'  for  a  particular  vessel 
the  value  shoul''  ''  noteil,  and  it  is  convenient  to  make  a  table 
showing   the  <  tion    that  will  have    to   be  made    tor  rvery 

resistance  that  .ill  be  iound  to  be  jwssessed  by  any  fluid  that 
will  be  subsequently  examined.  This  will  be  found  to  save  a 
great  deal  of  Calculation.  The  procedure  with  the  fluid  to  be 
tested  is  exactly  the  same.  Th"  fluid  to  be  tested  replaces  the 
decinormal  KCl  in  the  vessel  after  the  latter  has  been  cleaned  in 
the  manner  already  described.  The  little  piece  of  aj)paratus  is 
placed  in  the  thermostat  at  the  same  tcmjxjrature.  ami  then  the 
estimations  carried  out  exactly  as  before,  a  mean  reading  Ix-ing 
taken. 

We  have  now  the  following  relations  : 

The  resistance  to  be  estimated :  resistance  in  box :  :  (i  :  h, 
where  a  is  the  length  from  zero  on  scale  to  movable  jwint  wfien 
the  telephone  is  silent,  and  h  is  the  distance  from  the  latter  to 
the  end  of  the  metre. 


ICXJO 


A  ready  reckoner  has  been  provided  by  Obach  for  reading 
off  the  values  of  all  these  fractions  without  labour  (see 
Appendix). 

Now,  the  conductivity  of  the  fluiil  is  found  when  the  resist- 
ance-capacity of    the    vessel    is   di-,ided   by   the    resistance   of 

the  fluid. 

This  is  specific  conductivity,  or  the  conductivity  possessed 
by  a  volume  of  fluid  i  square  cm.  in  area,  and  i  cm.  deep.  This 
is  a  convenient  mode  of  expressing  the  conductivity,  and  will 
be  found  to  te  adopted  in  most  of  the  pa})ers  published  on  the 
subject  abroad.     The  letter  k  is  used  to  express  it  in  brief. 

Another  mode  of  expressing  the  conductivity  is  in  terms  of 
the  number  of  gram-equivalents  of  electrolyte  in  a  vessel  whose 
electrodes  are  i  cm.  apart,  no  matter  how  large  the  electrodes. 
This  is  the  equivalent  conductivity,  represented  by  the 
symbol  A. 

The  molecular  conductivity  is  the  value  when  the  result  is 
expressed  in  terms  of  numl)er  of  gram  molecules  of  electrolyte 
in  the  vessel.  It  is  the  same  as  the  fornici  with  monovaleiit 
electrolytes. 


Ii6 


STUDII'.S  I.N   prNcruKK-FLUins 


i  i 


Tlif  I'ciuivali'iit  a)mlu(tivity  is  (•iilculatc'd  by  dividing  the 
specific  (.oiiductivity  by  tlic  iuuiiIht  of  giam-e(iuivalcnts  ix;r 
cubic  ctntiiiKtio.  TIic  (>l)jcction  to  this  moile  of  expression 
is  tliat  in  the  fluids  undtr  consideration  we  do  not  know  the 
grani-i(iuivak'nt  per  ctiitiniftic,  and  it  is  not  wise  to  express  it 
in  terms  of  NaCl  for  reasons  already  fully  dealt  with. 

Resii.ts  of  1'^x.\mis.\ti()N  of  th^  Fi<i;ezin(;-point  and  of 
THE  CoNOfCTlviTY.  — Since  both  these  modes  of  study  prac- 
tically form  the  basis  of  the  wor!;  which  is  herein  recorded,  it 
is  minecessary  to  specially  collect  together  the  values  obtained 
in  the  case  of  various  puncture-fluids,  since  these  will  be  found 
under  tlu'  api)roi;riate  headings  througnout  the  lx)ok,  and 
esiH'cially  in  Sections   III.  and   IV'. 

We  may  refer  to  Talile  X\'I.  for  the  values  obtained  in  many 
pleural  and  jwritou'^al  fluiils.  and  Tables  XVI.  to  XIX.  for  the 
(iectroconductivits  of  fluids.  Fiuther  details  are  also  given  in 
the  ajXH'ial  cases  reporteil  in  Section  \'I. 

The  .-"pplication  of  these  methotls  of  study  to  other  problems 
which  are  of  interest  in  the  lUvly  (»i  puncture-fluids  is  illus- 
trated by  the  detection  of  autolytic  jihenomena  as  recorded  in 
Table  XI.,  by  the  examination  of  the  osmotic  concentration  of 
the  blood  at  the  same  time  as  that  of  the  puncture-fluid  *  (Section 
III.),  and  of  the  urine  secreted  at  the  time  of  tapping  the  effusion 
to  be  examined  (Section  VI.). 


The  foil  wing  ixampV.^s  illustrate  the  valiio  of  this  nuthod  of  .study. 
Allaria  inado  out  that  the  conductivity  of  tlie  blood  is  i:,)t  increased  in 
uraemia,  showing  thst  the  cause  of  ur.xmia  must  lie  in  an  accumulation 
ol  the  iiH'KinV  decomposition  products. 

Sasaki  also  employed  the  method  lor  studying  the  ascitic  i.iitl  in  cases 
of  experimentally  induced  nephiitis.  and  concluded  that  there  was  no 
ictfiili'ii!  of  electrolvtes  in  the  fluids  or  tissues  in  cases  of  ur.-cmia. 

Again,  .\sher  employed  the  method  in  order  to  determine  whether 
bloc  1-serum  were  a  solution  or  a  mixture. 

Its  application  to  the  detection  of  adsorption-plunoniena  was  gone 
into  in  Section  I. 

Other  Methods  of  Determining  Osmotic  Pressire.— 
Hamhur'^cr's  rcd-cdl  method.— \\\\m  a  vegetable  cell  is  placed 
in  watery  salt  solution  of  a  different  concentration  to  itself,  water 
wil!  p.i.ss  either  out  of  or  into  the  ]irotoplasm  until  the  two  fluids 


*  Cohn  elaborated  tliis  idea. 


rilYSICO-CIIEMICAL  I  XAMINATIOX 


"7 


are  at  the  same  concentration.  The  1  wo  soliit  ions  are  now  isotonic. 
If  water  passes  out  of  the  cell  into  the  water  the  iJrotoplasin  will 
contract  and  vacuoles  appear.  De  Vries  ascertaineil  that  there 
are  definite  relations  between  the  molecular  concentration  of  salt 
solutions  and  the  apix-arance  of  this  phenomenon,  and  FlamburKer 
found  that  if  red  cells  be  used  in  i)lace  of  tfie  vegetable  cells, 
similar  rules  will  hold  good,  with  the  difference  that  m  this  case 
alisence  of  tonicity  will  be  shown  by  the  passage  of  h;tmo.,dobin 
out  of  the  red  cell. 

In  i()o()  Hamburger  published   his  method  of  estimating  the 
osmotic  pressure  on  this  princi|)le.      The  volume 
of  the  red  cells  depends  on  the  osmotic  pressure  of 
the  solution  in  which  they  lie. 

The  fluid  to  be  tested  is  i)laced  in  a  sj)ecial 
tulx'.  like  that  indicated  in  the  accompanying 
figure.  funnel-sha|)ed  above,  and  calibrated 
below.  Into  other  similar  tul)es  are  placed  salt 
solutions  of  different  strengths  (o().  lo,  ii. 
I "2,  I  3,  I •4.  15.  i()  i)er  cent.  XaCl).  To  each 
tube  is  now  added  002  to  004  cc.  of  defi- 
brinated  blood,  and  after  mixing  each,  and 
allowing  to  stand  for  half  an  hour,  the  tubes 
are  all  centrifuged  till  the  dejwsit  of  red  cells 
ceases  to  alter  in  amount.  The  osmotic  pressure 
of  the  fluid  will  he  the  same  as  that  of  the 
solution  of  NaCl  in  which  the  volume  of  the  dejxisit  is  the 
same  as  that  in  the  fluid  tested.  The  graduation  of  the  tulx's 
enaliles  this  volume  to  be  read  off  accurately.* 

The  sole  objection  to  the  method  is  that  it  involves  the  use  of 
a  very  jwwerful  centrifuge,  an  apparatus  which  is  out  of  the 
question  for  the  practitioner,  and  probably  few  clinical  labora- 
tories can  find  accommodation  for  an  instrument  which  ii 
constructed  to  hold  twelve  of  the  tubes  and  revolve  3,000 
times  a  minute. 

Besides  this  difhculty  the  method  fails  in  those  cases  in 
which  the  fluid  to  be  tested  causes  haemolysis  at  the  outset, 
and  it  also  fails  in  the  case  of  fluids  which  contain  substances 
devoid  of    any   influence  on   the  volume  of   the  corpuscles   in 


Fig,  5. 

HamlmrKcr's 
Pipette. 


Obtainable  from  J.  J.  Bohm,  Groningen. 


Ii8 


STUDIES   IN    IL'NCTL'KK-ll.UlDS 


l! 


sintc  of  then  infliu'inr  on  tin-  osmotic  jnessuro.  I'rca.  for 
instance,  which  .Uvidcs  itself  evenly  over  corpuscle  and  mednim. 
will    not     show    any    api^reciahle    change    by    the    ha'niolytic 

methoil. 

Another  difference  between  the  results  obtained  by  the  red 
corpuscle   niethol   and    those   obtained    by   the   f  rcezing- point - 
determination  method  lies  in  the  fact  that  in  the  former  case  one 
ascertains  the  strength  of  a  solution  of  s jdium  chloride  with 
which  blood-serum,  say.  is  isotonic,  whereas  in  the  other  case  one 
learns  the  total  concentration  of  the  solution,  no  matter  whit 
salts  are  present.     Blood-serum,  or  ascitic   fluid,  etc.,  doi'S  not 
contain  NaCl  only,  but  carfwnates.  phosphates,  sugar,  urea,  etc., 
so  that  one    is  not  strictly  accurate  in  expressing  them  all  in 
terms  of  NaCl.     Then,  again,  in  diluting  an  albuminous  fluid  like 
blood-serum  with  water  m  order  to  test  its  tonicity,  one  does  not 
diminish    the  osmotic  pressure  in  the  same  proiKjrtion  as  the 
dilution,  because  one  not  only   increases    the  ionisation  of   the 
molecules  each  time.*  but   the    resistance  to  the  movement  of 
the  ions  is  lessened  by  the  pressure  of  the  relatively  less  colloid 

matter. 

A  further  error  arises  from  the  fact  that  red  corpuscles  are 
permeable  to  different  ions  in  different  degree,  and  not  only  that, 
but  the  i^ermeabilitv  of  red  cells  for  ions  varies  with  the  actual 
condition  (the  "  health,"  as  it  were)  of  the  red  cells  themselves. 
The  tonicity  of  serum  tested  in  this  manner  and  expressed  m 
terms  of  NaCl  will  not  corresiwnd  precisely  to  that  expressed 
in  terms  of  Na..,CO.,  where  sodium  carbonate  was  used  in- 
stead of  sodium  chloride  ;  and  so  also  the  tonicity  would  not 
correspond  with  that  expressed   in  terms  of  such  a  substance 

as  cane-sugar. 

The  error  which  might  arise  in  not  using  absolutely  fresh  red 
corpuscles  is  not  important,  provided  they  are  used  with  aseptic 
precautions  and  not  kept  unduly  long. 

For  these  reasons,  then,  the  method  cannot  rejilace  cryoscopy, 
but  it  forms  a  valuable  adjunct  as  affording  information  about 
such  substances  as  urea  in  a  fluid.  (See  under  Amniotic  Fluid, 
Section  III.). 

•  Dilution  ot  8  per  cont.  NaCl  with  equal  quantity  of  water  does  not 
l.alvc  the  osmotic  pressure,  but  leaves  the  latter  only  a  little  less  than  it 
was  before,  since  there  are  now  more  free  ions  present  than  before. 


rilYSICO-CIIEMICAL   EXAMINATION 


119 


Th>!  following,'  table  will  show  the  application  of  the  method 
(from  Hamburger's  pa}ier,  Biochem.  Zcit.  I.). 


Kluids. 


Volume  of  Uepoails  of  Ktd  Cella  after 
CentrifUKaliiing. 


J  hoi  .-.  !}hou'.  .'jhour.  |)hour.  Uhour.   ijoiiD.  1  lomin. 


58 

5" 

55 

50 

5« 

54 

59 

54 

5S 

49 

55 

5' 

56 

50 

54 

49 

50 

46 

5« 

4b 

48 

47 

46 

46 

46 

47 

47 

46 

46 

4b 

50 

49 

49 

49 

49 

52 

50 

49 

49 

49 

48 

47 

47 

47 

47 

48 

47 

47 

47 

47 

47 

4t. 

45 

45 

45 

47 

46 

45 

45 

45 

44 

43 

43 

43 

43 

44 

43 

43 

43 

43 

Lymph 

0-9%  Natl  '. 

o-9S%NaCi; 
I  %  NaCl  : 
l05%NaCl! 


The  objections  mentioned  also  apply  to  the  method  devised 
by  Sir  A.  E.  Wright,  although  in  this  case  the  apparatus  has  the 
advantage  of  extreme  simplicity.     For  comparing  the  osmotic 
concentration  of  blood-serum  and  urine  of   a  patient  it  is  very 
useful,  l^ecaase  so  small  a  quantity  of  fluid  is  needed.     In  this 
method  the  familiar   pij)ettes  are  employed,  and  a  mark  Ix-ing 
made  on  the  stem  of  the  capillary,  different  dilutions  of  blood, 
with  a  standard  solution  of  NaCl  ("  N  "),  until  the  particular 
dilution    is    found   that   just  causes   haemolysis.     Supiwse  two 
volumes  of  a  N'/  35  NaCl  solution  cause  haemolysis  of  one  volume 
of    blood,    i.e.  two  volumes   of   a  oi67-ix'r-cent.    NaCl    cause 
hjemolysis  of  one  volume  of  blood.     The  urine  is  then  diluted  in  a 
similar  manner,  using  distilled  water  in  this  case  until  it  is  found 
that  two  volumes  of  the  diluted   urine  when  mi.xed      .th  one 
volume  of  blood  just  cause  haemolysis.      Supix)se  the  dilution 
of  urine  is  twelve-fold.     Then  the  twelve-fold  dilution  of  urine  = 
N,  35  saline  =  0167  j^r  cent.  NaCl.     The   urine   is   therefore 
equivalent  to  2004  \yex   cent.  NaCl.     Finally,  the  serum  to  be 
tested  is  diluted  in  the  same  way,  till  a  dilution  is  found  which 
just  causes  haemolysis  of  one  volume  of  blood.     The  equivalent 
of  the  serum  in  terms  of  NaCl  is  again  calculated,  and  may  be 
compared  with  that  of  the  urine. 

The  clinical  utility  of  the  metho  1  it  is  not  possible  to  over- 
estimate, but  as  an  exact  means  of  determir-ng  osmotic  pressure 
it  is  unfortunately  of  no  avail,  for  the  same  reasons  that  the 


I20 


SirhlHS   IN    I'LNCTUUE-FI.UIDS 


r 


hitmolytic  inctliod  ot  HamhinK'^'i'  l^i'l-^  <>"  '^'i'  <>thiT  h;iiul,  the 
method  may  1k'  used  in  place  ot  HamhuiKer's  to  amplify  the 
values  ascertained  by  cryoscopy.  ami  throw  li|,'ht  on  the  abun- 
dance or  otherwise  of  substances  in  a  tKud  whit  h  are  iH^rmeable 
to  red  (ells. 

I.inihtck's  mdhod  consists  in  placing  i  cc.  of  increasing  (by  o o j 
\X'\  cent.)  (oncentrationsof  NaCl  intoeach  of  sixteen  small  tubes 
and  adding  a  trace  of  blixnl  to  each.  After  six  hours  it  is  noted 
in  which  tube  haniolysis  has  occurred.  The  method  takes  into 
account  the  resistance  of  the  red  cells— quite  another  subject. 

The  (inferential  tcnsimticr  of  Friedenthal  has  the  ailvantage 
of  <'nabling  the  variations  in  osmotic  jMessure  to  he  uuitchcd.  I)ut 
neci'ssitates  the  studv  of  the  body-fluid  nithotit  its  ^ascs.  since 
these  will  W  removed  by  the  mercury  pumi)  In-longing  to  the 
apparatus. 

B.  The  Critical  Solution-point.— Quite  recently  (February 
1908)  W.  K.  (ielston  Atkins  published  a  new  })hysico-cheniical 
method  of  examination  of  urine,  which  he  advocated  in  place  of 
cryoscoiiy  for  the  diagnosis  of  the  functional  efficiency  of  the 
kidney.  Without  discussing  the  value  which  is  to  lie  attached 
to  this  mode  of  diagnosis,  one  may  refer  to  the  method  as  one 
likely  to  Ix'  of  interest  in  the  study  of  those  puncture-fluids 
which  do  not  contain  much  albumen. 

The  method  dei)ends  on  the  fact  that  if  phenol  and  water  be 
shaken  together  at  room-temi)eraturc,  they  will  not  completely 
mix,  whereas  on  raising  the  temiK-rature  a  point  will  i>e  found 
at  which  the  two  fluids  just  become  completely  misciblc.  This 
temi)erature  is  the  critical  solution-temperature,  and  is  a  constant 
for  the  particular  mixture.  Any  deviation  from  the  critical 
temiierature  causes  an  opalescence  to  api)ear  (blue  by  reflection 
and  brown  by  transmission).  A  series  of  mixtures  of  phenol 
and  water  present  a  series  of  increasing  critical  solution-tempera- 
tures, a  maximum  temix-raturc  (the  critical  solution-iwint)  being 
reached  on  the  curve  so  obtained.  In  some  cases,  however,  it 
is  the  opalescence  which  is  the  guide  to  the  critical  solution-point, 
and  not  the  maximum  temi^K'rature  on  the  curve.  The  fact  that 
the  addition  of  a  third  substance  to  the  mixture  raises  the 
criticalsolution  ti'm]ierature  to  a  degree  depending  on  the  concen- 
tration of  the  added  substance  has  led  to  the  suggestion  of  the 
method  for  the  pur|X)ses  indicated  above. 


riSVSKO-CIIEMKAL   EXAMINATION 


1^1 


The  pioa-dun-  is  as  follows  :  some  crystallmi-  j^honol  (in  p. 
40^  C.)  is  placfd  ill  a  dry  test-tuln-  an<l  distilli'<l  water  poured  in 
till  the  jjhenol  is  covered.  The  tuln;  is  then  warmed  till  the 
contents  are  homogeneous.  On  cooling  a  fog  apiH' irs.  and  with 
certam  dilutions  this  fog  is  preceded  by  an  oi)alescence.  If 
opalescence  iloes  not  appear,  more  water  is  added  till  it  does  do 
so  on  cooling.  The  temiH-rature  is  then  noted.  Further  aildition 
of  water  again  will  prevent  the  opalescence  from  appearing.  The 
tem|X'rature  in  which  a  fog  appears  in  the  mixture  having  the 


^"^ 

— 

3 

Tw 

J 

+■ 

■^ 

V 

t 

'V 

X 

y 

c 

N 

•x^ 

JC 

^ 

V 

^ 

— _ 

.__ 

•^ 

-  < 

L 

r^ 

*^ 

--> 

^ 

4<f 

■^ 

'^ 

M 

2ir 

" 

1 

1 

1 

i 

u. 

i 

< 

r~ 

fJM 

b 


Fig.  f). — The  critical  solution-point  (c)  ;  a.  the  curve  showing  thr  critical 
.solution  temperatures  at  liiffeient  mixtures  of  phenol  with  a  specimen 
of  ascitic  fluid  (case  of  cirrhosis  of  the  liver);  h,  the  curve  in  the 
case  of  phenol  and  distiUetl  water. 

best  opalescence  is  the  critical  solution-ixjint  and  is  constant  for 
each  sample  of  phenol.  Having  ascertained  this,  the  //(/I'l/  to  he 
tested  is  treated  with  phenol  in  the  same  way,  and  the  difference 
in  the  temperatures  in  the  two  cases  is  observed.  This  difference 
is  the  rise  in  the  critical  solution-point  required. 

For  instance,  in  a  case  of  peritoneal  fluid  the  rise  was  found 
to  he  16-  r. 

The  accompanying  figure  serves  to  explain  the  principle  of 
the  method  (Fig.  6). 


12; 


STi:i)IF.->  IN    rUN(Tl  KK-H.UIDS 


lis 


!!  i 


( .  The  Concentration  of  Hydrogen   Ions.     It   is  now 

\v<!l  known  tliat  tlif  snni)lf  nuthod  ol  tt-.tni^  llif  ir.ution  of  a 
Huid  l)V  rmans  ot  Munr  "  imlu ator  "  docs  not  t,'ivr  a  corn-ct  idea 
of  Its  real  acidity  or  alkalinity.  I  Ins  is  U'causc  tin-  n-amint  with 
wliirli  one  titiati-s  is  mtt-iinK  into  clu-mical  (ombination  with 
tlu-  indicator  as  woll  as  with  tin-  fluid  to  tx-  tcst«'d. 

Thus,  It  has  hicn  |H)int«'d  out  that  a  <U'cinc)rinal  M»lution  of 
s..."..;...  carlMmatf.  U'ln^  partly  dissociated  (by  ji;  jht  cfnt). 
contains  as  many  hydroxyl  ions  ;is  a  oooji;  ;i  solution  of  soda, 
and  it  one  titrates  this  alkali  with  an  acid,  the  effect  of  adding 
the  latter  is  to  bind  OH  to  iT,  when  the  ecjuilibriuin  is  at 
once  disturlH.'d.  and  more  sodium  carbonate  dissociates.  These 
processes  will  occur  at  each  addition  of  acid,  until  all  the  carbon- 
ate has  becoiiK-  dissociated.  Hy  tliis  time  as  much  acid  will 
have  been  used  as  if  the  carbonate  had  been  caustic  soda,  and 
one  would  be  led  to  suppose  that  the  alkalinity  of  a  decinormal 
solution  of  the  carlH)nate  was  the  same  as  that  of  a  decinormal 
solution  of  soda,  whereas  it  is  really  the  same  as  a  oooji;  u 
solution.  In  other  words,  we  have  fn-en  ascertaining;  how  much 
acid  is  needed  to  convert  all  the  sodium  carbonate  present  into 
NaCl,  or  Na,SC),,  or  NaNO.,  according  t(»  the  acid  used,  whereas 
we  wish  to  know  how  many  free  OH  ions  are  present.  In  the 
case  of  i)uncture-fiuids,  at  any  rate,  it  is  the  number  of  free 
OH  tons  which  impart  to  them  their  (as  it  were)  physiological 
ilkalinity.  These  free  ions  have  been  called  "  actual  ions," 
while  the  others  are  called  "  i)otential." 

It  is  obvious  that  in  the  case  of  puncture-fluids  the  numl)er 
of  free  OH  ions  jh-T  litre  will  Ik-  very  much  less  than  they  are 
in  a  decinormal  or  even  a  centinormal  solution  of  sodium  car- 
bonate. In  fact,  if  we  take  the  number  of  grams  of  H^  ions 
present  in  each  litre  of  puncture-fluid  we  shall  find  it  to  l>e  only 
5  or  b  X  ID  **  (i.e.  000000005  gm.  ix;r  litre),  which  is  at  first 
sight  so  small  an  entity  as  to  be  negligible. 

The  quantity  is,  nevertheless,  of  very  great  importance,  as 
can  be  readily  shown  from  a  reference  to  the  ionic  concentra- 
tion of  ji'(j/t'r  itself.  In  the  case  of  water  there  is  very  little 
dissociation  present,  and  there  is  a  definite  relation  between  the 
amount  of  H*  and  OH",  which  is  expressed  by: 


C„+ X  Co,,- =  0-64  X  10-" 


IIIYSKOt  MKMICAL   tNAMINATlON  12? 

whoro  of)4x  10  "  constitutes  the  "  dissoriation-constant  "'  W 
0aslric  Jfj^c€ ^ 


TropttoUn   000 

I Tear»        ,  .,    ■  , 

^---4^Ptritoneal  fluid 


8.. 

""  iP^nol  Phthqlein. 

^'\ Pancreatic  '^ Juice 


i 

OD 

Fia.   ;.— Diagram  to  illustrate  the  mcaninn  of  the  term  'acidity." 

watpr  at  the  temUratnre  i8'  C  In  a  neutral  solution  C„  =  C,,,,, 
or  each  has  the  value  8  x  lo  ^  while  m  acid  solution  C„  is 
greater  than  C.,„  ;  in  alkaline  sohition  less,  the  equation  holding 


124 


STUDIES   IN    ILNCTfKE-FLUIDS 


goo  1  in  all  casos.  The  more  the  C,;  pre[K)nderates  the  less  will 
be  the  C,,,,. 

It  ioUows,  then,  that,  f,'iven  either  C,,  or  C.„,,  one  can  calculate 
the  other. 

The  diagram  (F'ig.  7)  has  been  devised  to  illustrate  these 
consitlerations  gra])hically.  The  curve  represents  the  varying 
concentration  of  H  ion>  as  one  passes  from  a  highly  acid  solution 
at  A  to  one  which  is  alkaline  at  B.  In  this  curve  the  ordinates 
correspond  to  fractions  of  normal  solution  of  HCl,  anil  it  will 
be  ol)served  that  as  one  passes  from  tlie  neutral  point  in  the  direc- 
tion of  A,  the  concentration  of  ions  in  terms  of  10  '^  is  constantly 
diminishing,  though  the  curve  does  not  rise  nuich  from  the  hori- 
zontal. Tl'.at  is  to  say.  the  distance  travelled  longituflinally 
becomes  greater  and  greater  with  each  increment  in  the  strength 
of  acid.  On  the  other  hand,  near  the  neutral  point  a  slight 
journey  to  the  left  means  little  change  in  concentration  of  ions, 
but  is  commensurate  with  a  considerable  loss  of  acidity,  because 
the  curve  rapidly  turns  down  to  the  zero-point.     At  this  point 

When  the  curve  has  passed  the  neutral  point  and  comes  to 
represent  an  alkaline  solution,  the  reverse  takes  place,  and  a 
small  distance  to  the  right  means  a  small  change  in  con- 
centration of  H  ions,  but  a  considerable  degree  of  increase  of 
alkalinity,  and  as  one  passes  towards  B  one  traverses  a  con- 
siderable distance  before  one  reaches  any  increase  in  the  strength 
of  alkali. 

Put  in  other  words  again,  the  stronger  the  acid  is,  the 
more  rapidly  does  the  concentration  increase  with  each  increment 
of  strength  :  the  stronger  the  alkali  is,  the  more  effect  on  concen- 
tration of  OH  does  a  slight  increase  in  strength  of  alkali  produce. 
The  higher  the  curve  rises  above  the  line,  the  more  acid  is  the 
fluid,  while  the  lower  it  falls  below  the  line  the  more  alkalinity 
does  it  represent. 

The  reaction  of  the  fluids  of  the  body  is  all  focussed  round 
the  "  neutral  {xjint,"  with  the  sole  exception  of  the  gastric  juice,* 
which  apix\irs  well  on  the  left  end  of  the  curve,  and  it  is  just 
about  the  neutral  point  that  the  fluids  come  to  be  almost  com- 
pletely dissociated.     A  solution  of  HCl  which  is  so  weak  as  to 


I'aucreatic  juice  will  be  well  on  tlic  riijht  cid  ot  thf  curve. 


PHYSICO-CHEMICAL   EXAMINATION  125 

be  neirly  neutral  may  be  looked  uiwn  as  completely  dissociated, 
so  that  its  ionic  concentration  is  exactly  the  same  as  the  gram- 
equivalent  of  H^.  The  ixjsition  of  the  various  fluids  which 
api^ear  in  the  table  on  page  133  is  indicaten  un  the  curve  as  far  as 
the  size  of  the  drawing  jwrmits.  and  the  degree  of  acidity  which 
is  necessary  to  jiroduce  any  effect  on  the  common  "  indicators  " 
has  been  marked  on  the  curve  in  order  to  bring  these  con- 
ceptions more  into  line  with  the  old  conception  of  acidity  or 

alkalinity. 

We  now  come  to  the  curve  indicated  by  dotted  lines.  In 
this  case,  jwsition  below  the  horizontal  line  means  "lative 
diminution  of  C„„,  and  when  the  curve  rises  above  the  line 
it  indicates  absolute  alkalinity  of  the  fluid.  It  will  be  at  once 
evident  that  the  further  we  go  towards  B,  the  greater  the  C,,„ 
and  the  less  the  C,„  since  the  Co,,  curve  is  constantly  rising 
and  the  other  falling.  Just  as  a  slight  increase  in  acidity 
makes  the  curve  travel  a  long  way  horizontally  towards  A 
(corresjx)nding  great  increase  in  concentration  of  H  ions),  so 
a  slight  increase  in  alkalinity  is  accompanied  by  a  very  great 
decrease  in  concentration  of  OH  ions,  since  the  curve  elongates 
in  exactly  the  same  way  in  the  other  direction.  When  we 
come  to  the  neutral  point  the  OH  curve  actually  passes  above 
the  line,  because  the  solution  is  definitely  alkaline,  and  with 
the  increase  in  alkalinity  the  C,„,  curve  constantly  rises  higher 
and  higher  towards  infinity. 

The  only  substance  which  coincides  with  the  neutral  point 
IS  water,  and  it  is  at  this  point  that  the  two  curves  cross, 
showing  that  C„  =  C„„.  The  symmetrical  character  of  the 
curves  shows  that  the  product  C„  x  C.,„  remains  constant, 
and  the  dotted  lines  drawn  between  the  two  curves  at  the 
various  points  representing  the  special  body-fluids  demonstrate 
their  reaction.  Thus  the  upper  limit  of  acidity  of  normal 
urine  is  indicated  by  a  line  which  passes  from  the  C„  line  to 
the  C,,H  line,  the  point  on  the  former  lying  as  much  above 
"  zero  "  as  does  the  corresponding  point  on  the  C ,«  curve  lie 
below  it. 

The  varying  degrees  of  H+  ion  concentration  which  are 
necessary  before  given  "  indicators  "  will  react,  are  shown  in  the 
following  scheme,  quoted  by  Hober  from  the  work  of  Saleesky 
and  Fels. 


126 


STUDIES   IN    rUNCTUKE-KLUIDS 


I 


U 


Indicator. 

C'i>li>ur-chanKe. 

Conccntratiiin  of  H  i<mt. 

Tropaolin  uuo 

Orange  to  Red 

o-oocx>63 

PhenolphlhaUin 

Ri.l 

0174 

Curcumin  \V    ... 

Red 

024 

Lacmoid 

aiue  to  Rtd 

11 

/.-nitrophenol  ... 

Yellow           

18 

f  Yellow           

(Red 

590 

Methyl  Orange 

50000 

Congo  Red 

Blue 

I73S0 

Methvl  Violet  ... 

Violet             

4l6<^o 

This  table  shows  how  low  a  concentration  suffices  to  produce 
a  blue  coloration  with  lacmoid,  whereas  methyl  orange  is  turned 
red  with  a  concentration  of  3  x  10  '. 

There  are  various  means  by  which  the  numl^er  of  hydrogen 
ions  i)resent  in  a  given  fluid  may  be  ascertained.  The  following 
are  the  most  important : 

Determination  of  C„  and  C,,„  by  the  Use  of  an  In- 
dicator Series. — The  observation  which  has  l)een  made  that 
different  indicators  vary  in  their  sensitiveness  to  acids  and  alkalis, 
so  that  the  colour  change  is  juoduced  only  by  a  definite  concen- 
tration of  H,  has  led  to  the  idea  that  a  scale  of  indicators  such  as 
is  given  in  the  table  will  enable  the  concentration  of  H  ions  in 
any  particular  fluid  to  be  estimated.  For  instance,  blood-serum 
will  not  redden  with  phenolphthalein,  so  that  it  must  contain 
at  least  01  to  03  x  10  'H^,  a  value  which  agrees  with  that 
found  electrometrically.  In  the  case  of  fluids  which  are  so  highly 
coloured  that  one  cannot  use  an  indicator,  it  is  jwssible  to  make 
one's  observations  by  noting  the  disappearance  of  absorption 
bands  in  the  spectrum  (Pels).  In  the  method  of  Sir  A.  E.  Wright 
the  fluid  is  diluted  so  many  times  with  a  standard  solution  of 
acid,  until  the  mixture  ceases  to  redden  litmus  paper. 

The  Inversion  Method. — This  is  only  available  for  the  study 
of  gastric  juice.  It  depends  on  the  inversion  of  cane-sugar  by 
HCl.  The  H*^  acts  as  a  catalyst  and  undergoes  no  change  in 
the  process.  The  velocity  of  inversion  is  proportional  to  the 
concentration  of  the  free  H  ions,  and  the  reaction  is  a  mono- 
molecular  one.  The  jxjlarimeter  is  used,  and  the  degree  of 
rotation  observed  liefoio  the  action  of  acid,  and  after.  The  ratio 
of  the  velocity  of  the  fluid  tested  to  that  of  a  standard  solution 
of  Hri  is  made  nut  in  this  way.  This  method  has  already  been 
referred  to  in  Section  I.,  Sub-section  "  Ferments." 


Ill 


PHYSICO-CHEMICAL  EXAMINATION 


127 


The  Methyl- \cetate  Method  requires  no  complicated  ap- 
paratus, and  the  calculations  are  much  simpler.  Here  also  there 
is  a  catalytic  process,  and  is  only  applicable  to  such  a  strongly 
acid  fluidas  gastric  juice.  A  given  quantity  of  fluid  is  incubated 
with  a  given  quantity  of  methyl  acetate,  a  similar  quantity  of 
n  20HCI  being  treated  in  the  same  way  as  a  control.  After  four 
hours  each  is  titrated.  The  presence  of  neutral  salts  interferes 
with  this  reaction  (chlorides  and  nitrates  accelerate,  sulphates 
depress  the  velocity  of  reaction). 

The  digestion  of  egg-white  dej^nds  for  its  velocity  on  the 
concentration  of  the  H  ions,  so  that  one  could  estimate  this  by 
noting  the  degree  of  digestion  (weight  before  and  after).  Here 
again  free  acid  is  essential  to  the  process. 

The  Dil.^tometer  Method.— This  method  is  unfortunately 
not  available  for  puncture-fluids  because  of  the  small  number  of 
OH-  ions  present,  and  is  uncertain  in  the  presence  of  neutral  salts, 
while  the  presence  of  ammonia  renders  the  method  useless 
because  it  enters  into  combination  with  the  acetone,  and  thus 
inhibits  the  velocity  of  reaction.  The  method  dei>ends  on  the 
conversion  of  diacetone  alcohol  CHo .  CO  .  CH, .  C(CH3) .  OH  mto 
acetone,  a  change  which  is  associated  with  an  increase  in  the 

volume  of  the  fluid. 

The  Diazoacetic-ether  Method.— Bredig  has  pointed  out 
that  this  method  forms  a  very  convenient  one  for  ascertaining  the 
concentration  of  the  H  ions.  WTien  in  contact  with  acid  the 
following  reaction  occurs  with  great  rapidity,  and  nitrogen  is 
liberated  (read  off)  : 

N, :  HC  .  COAH.  +  H,p  =  OH  .  H.,C  .  CO,C.,H,  +  N, 

SO  that  the  progress  of  the  reaction  is  very  readily  watched.  Since 
the  velocity-constant  of  the  reaction  is  proportional  to  the  C„ 
it  becomes  a  very  useful  method,  and  is  quite  sensitive  even  at 
the  temi:.erature  of  the  room.  This  reaction  is  also  monomolecular. 
Bredig  states  that  it  will  measure  C,,  even  in  ji/nn  to  irnnsis  " 
dilution  with  exactitude,  that  is  jaUamxi  S™-  hydrogen  per 
1,000  cc.  so  that  it  is  applicable  to  puncture-fluids. 

It  is  evident  that  these  methods  are  either  inapplicable  to 
puncture-fluids,  or  that  they  are  liable  to  be  rendered  inaccurate 
by  the  presence  of  salt,  which  certainly  occurs-^ometimes  in 
considerable  amount— in  these  very  fluids. 


128 


STUDIES   IN    rUNCTURE-FLUIDS 


(i  i 


ill 


The  only  method  which  does  not  present  these  difficulties  is 
that  in  which  "  gas  chains  "  are  employed,  and  unfortunately 
labours  under  the  insuperable  objection  that  it  is  too  complicated 
and  lengthy  for  general  use.  However,  it  is  worthy  of  a  brief 
consideration,  as  some  imjwrtant  investigations  by  C.  Fo^  have 
been  made  on  various  physiological  fluids  which  have  gone  far 
to  show  that  ionically  the  fluids  of  the  body  are  universally 
j)ractically  neutral. 

Thf.  C()nckntk.\tion-chaix  Method.— Suppose  that  in  each 
of  two  small  vessels  containing  zinc  sulphate  solutions  (each  of 
different  strength)  there  is  placed  a  zinc  electrode.  In  each 
case  there  will  be  a  tendency  for  zinc  ions  to  pass  into  the 
solution.  This  hapix'ns  with  a  certain  force  depending  on  the 
concentration  of  the  zinc  sulphate  solution.  If  the  osmotic 
pressure  of  the  zinc  ions  in  the  solution  be  less  than  the  force 
with  which  ions  tend  to  leave  the  electrodes,  ions  will  pass  from 
electrode  to  solution,  while,  if  the  pressure  in  the  solutions  is 
greater,  the  reverse  will  occur,  and  if  the  two  forces  are  equal, 
nothing  will  occur. 

In  the  first  case  there  are  positively  charged  ions  passing 
into  solution,  leaving  a  negative  charge  in  the  electrode  ;  in  the 
second  case  the  reverse  holds  good.  Therefore,  if  the  two 
electrodes  be  joined  by  a  wire,  and  the  two  vessels  be  joined  by  a 
tube  of  fluid,  a  current  will  pass  from  the  strong  solution  of  zinc 
sulphate  to  the  weak,  until  equilibrium  is  reached.  The  electro- 
motive power  of  this  current  will  depend  on  the  relative  strengths 
of  the  solutions. 

In  the  same  way  one  can  use  a  gas  chain  where  the  fluid  is, 
say,  strong  hydrochloric  acid  solution,  and  a  "  gas-electrode  "  * 
(e.g.  hydrogen),  while  the  other  vessel  contains  a  weak  acid  and 
another  hydrogen  electrode.  A  current  will  again  pass,  whose 
force  dejiends  on  the  difference  in  the  strengths  of  the  two  fluids. 
The  ions  concerned  in  this  form  of  apparatus  are  hydrogen  ions 
instead  of  zinc  ions,  so  that  by  this  method  we  can  calculate  the 
concentration  of  the  hydrogen  ions.  Suppose  that  in  one  of  the 
vessels  there  is  a  slightly  acid  fluid  (body-fluid),  and  in  the  other 
known  strength  of  HCl,  we  can  calculate  the  acidity  of  the  fluid 
in  terms  of  hydrogen  ions.     If  we  deal  with  an  alkaline  fluid 

•  A  gas  electrode  consists  of  a  platinum  electrode  coated  with  platinum 
black,  and  saturated  with  a  gas,  with  which  the  electrode  is  also  surrounded. 


I'HYSICO-CHEMICAL   EXAMINATION 


129 


such  as  blood,  and  use  oxygen  electrodes,*  and  a  known  strength 
of  sodium  hydrate,  we  can  calculate  the  concentration  of  the 


hydroxyl  ions,  and  so  ascertain  the  degree  of  alkalinity.  The  use 
of  oxygen  electrodes  is  permissible  for  acid  fluids  also  when  we 
wish  to  determine  CO,,  in  an  acid  fluid. 

*  If  one  uses  oxygen  electrodes,  and  soda  solution  in  one  vessel,  with 
an  acid  (luid  in  the  other,  we  shall  also  leaiii  the  concentration  of  iJic 
hvdroxyl  ions, 

9 


!  t 


130  STUDIES  IN   rUNCTURE-FLUIDS 

Fig  8  will  explain  the  way  in  which  the  apparatus  is  set  up 
The  Ras  chain  is  seen  to  he  made  up  of  two  six^cially  shaped 
ves.eK  each  furnished  with  a  platinum  (or  gold-Foa  *)  electrode, 
coated  with  platinum  (or  palladium)  black.     The  electrode  .s 
either  fused  into  the  glass  or  fits  in  with  a  hermetic  glass  joint 
The  vessels  are  joined  together  by  dipping  into  an  indifferent  fluid 
or  into  a  fluid  of  the  same  strength  as  the  standard  (o-oi  n  HCl). 
The  <econd  vessel  contains  the  fluid  to  1k^  tested,  and  hydrogen 
gas  is  sup,>osed    to   have    been   passed    in   till   the    electrodes 
are  covered  to  the  extent  shown  in  the  figure,  and  then  con- 
nections are  made  with  an  electrometer,  a  Wheatstone  s  bridge, 
and  a  battery.   The  electromotive  force  can  then  be  determined  by 
PoizKendorff's  method,  and  compared  with  that  of  a  standard  cell, 
B      C  1-^  the  kev  lor  making  and  breaking  the  circuit  at  the  time 
of  the  observat'ion.  and  A  is  the  movable  l^oint  on  the  bndge.f 
There  are  many  forms  of  gas  chain  J  available,  the  modihca- 
tions  being  mainlv  with  the  object  of  enabling  the  observations 
to  be  made  at  the  "temperature  of  the  body.     This  aim  introduces 
many  complications  which  come  to  render  the  method  useless  for 
the  clinical  pathologist.     It  is  therefore  wiser  to  adhere  to  the 
room  temperature,  and  ignore  the  change  which  temperature 
will  necessarily  introduce.     At  the  same  time,  it  must  not  be  for- 
gotten that  because  two  given  fluids  show  the  same  C  „  at  18-C.. 
they  will  not  necessarily  show  the  same  at  37^     I"  other  words, 
it  would  not  be  safe  to  assume  that  because  any  ascitic  fluid  has 

»  Foa  .howed  that  the  koW   covered  uitli  palladium  black  was  the 

■,„oresenMt>ve;   but  this  type  of  electrode  compared  unfavourably  with 

a    mm  electrodes  covered  with  platmum  black,  or  w.th  .nd.ated  mdm.n 

dec  rries-the  latter  bemg  found  to  acquire  a  constant  potenfa    much 

more  rapullv  than  the  second,  ami  the  second  than  the  pallad.ated  paha- 

um      Butthe  latter  adsorbs  much  more  H  than  does  plat.nated  platinum 

X    -^matter  of  fact,  .f  we  compare  the  C„  values  as  made  out  by  the  different 

ide  t^X  in  the  hands  of  various  observers,  there  is  found  to  be  very  httle 

eal  dUference.     Farkas  workn.g  w.th  platinated  platnu.m  electrodes  found 

blood  to  have  the  san.e  reaction  as  Fnmkel  d.d  w,th  palladmm  electrodes. 

(". I  in  each  case  being  I   x    lo"'. 

t  Hamburger   recommends  the   use   of   two  similar   re^stance  boxes 

in  place  of  a  bridge,  as  the  enormously  increased  length  of  the  w.re  so  ob- 

a.S  ensures  n.ore  delicate  observation.     The  use  of  these  ^^^  J^^  '"» 

details  of  the  metho<l  as  a  whole  are  given  m  the  second  volume  of  Ham- 

burger's    ■  lonenleliie.  '  , 

*    \n  "  all-glass  ■  gas  chain  seems  to  me  to  be  more  advantageous  thaa 
any'in  which  indiarubber  corks  are  integral  parts  of  the  gas  chain. 


PHYSICO-CHEMICAL   EXAMINATION 


131 


a  concentration  of  7-8xio~''  at  i8'C.,  which  a  given  specimen  of 
l)leural  fluid  also  hai)j>ens  to  have,  that  therefore  in  the  body,  and 
during  life,  they  are  identical  in  reaction.  Relative  accuracy, 
as  opjx)sed  to  absolute  accuracy,  is  one  to  which  the  reader 
needs  to  become  accustomed  here,  as  everj'where  throughout  this 
work.  It  is  enough  to  say  that  if  the  distinction  between  the 
value  at  18°  and  its  significance  at  the  temjxrature  of  the  body 
be  remembered,  the  results  become  at  once  legitimate.  The 
most  imjwrtant  objection  to  making  the  observations  at  37^  C, 
however,  is  that  the  various  factors  which  enter  into  the  subse- 
quent calculation  of  the  value  C,,  depend  on  measurements  which 
have  only  been  made  out  at  18^  and  25'  C,  so  that  correction 
formulae  (always  to  be  avoided)  become  essential,  and  it  is  far 
from  certain  how  far  these  formulae  tyay  be  trusted. 

The  procedure  in  an  actual  exjieriment  may  be  outlined  as 
follows  :  The  apparatus  being  connected  up  as  shown  in  the 
figure,  and  the  various  parts  being  prepared  for  use,*  the  commu- 
tator is  arranged  so  that  the  current  will  flow  through  the  normal 
element.  The  movable  jwint  A  is  adjusted  until  a  momentary 
closure  of  the  circuit  at  C  produces  no  movement  of  the  column 
of  mercury  in  the  electrometer.  The  reading  on  the  bridge  is 
then  noted,  and  the  ratio 

DE  _  F.M.F.  of  batten-. 

i>A  ~E.M.K.  ol  normal  elemtnt. 

1000  X  E.M.F.  ol"  normal  clement. 


Since  DE  is  itxxj  min.,  E.M.F.  of  battery  = 


DA 


The  commutator  is  now  altered,  so  that  the  gas  chain  is  in 
circuit  and  the  movable  jxiint  is  again  adjusted,  so  that  momentary 
closure  of  the  circuit  at  C  produces  no  movement  of  the  column 
of  mercury  in  the  electrometer.     The  ratio  again  holds  good,  and 

DE  ^  E.M.F.  of  battery 

DA'       E.M.K.  of  gas  chain. 

or,  substituting  the  symbol  tt  for  the  E.M.F.  of  the  gas  chain, 
and  inserting  1,000  for  DE  as  before, 

icxx)  K  E.M.F.  of  normal  element., 

^  -  —  i,x. 

or  we  may  still  more  simplify  our  procedure  by  inserting 
value  for  the  E.M.F.  of  the  battery,  when 
DA' 


the 


DA 


X  E.M.F.  of  normal  element. 


which  is  the  same  thing   as   saying    thai   the    E.M.F.   of    gas 
*  It  is  this  preliminary  preparation  that  makes  the  method  so  tedious. 


«32 


STUDIES   IN    rUNCTUKi:-KLl.-IDS 


resistance  of  gas  chain  :  rc- 


chain:  E.M.F.  of  normal  clement 
sistance  of  standard  cell. 

The  coupling  of  the  gas  chain  is  indicated  thus  : 


!I  1  Fluid  to  be  tested 


"  NaCI*   1  "NaCl  +  ooinHCl 

S  8 


H 


The  symbols  beneath  indicate  the  various  contact  potentials 
which  have  to  l)e  added  up  (algebraically)  in  computing  the  total 

K.M.F.  of  the  chain. 

However,  it  is  not  necessary  to  enter  into  the  details  of  the 
calculation  and  discuss  the  mode  of  introducing  n,  tt",  tt",  into 
the  formula  : 

5r  =  o-o575lop.  ^-, 

which  will  enable  the  concentration  of  the  H  ions  in  the  given 
fluid  to  be  calculated,  provided  the  observation  is  made  at 
ibout  17=  C  t  c.  is  the  concentration  of  the  H  ions  m  the  solution 
of  ooi  hHCI,  while  C„  represents  the  desired  concentration  of  the 
fluid.     Or  we  may  state  that 

log.  C„  =  log.c,-^,i^-=   -"--oItS- 

If  desired,  the  result  obtained  in  this  way  may  be  controlled 
by  ascertaining  C„„  in  the  same  way,  using  o.xygen  electrodes  in 
an  atmosphere  of  oxygen,  and  ooi  nNaOH  in  place  of  acid.., 
The  formula  already  given, 

Cii  =  Con  =  0-8  X  10   , 
will  enable  one  to  see  if  the  result  for  C„  has  been  arrived  at 

correctly.  ,  ... 

\  reference  to  the  two  formula;-(a)  one  for  estimating  ir  ; 
(b)  for  estimating  velocity  of  ferment-action-is  of  interest,  since 
the  graphic  representation  of  change  of  reaction  (acidity)  m  Fig.  7 
shows  a  remarkable  resemblance  to  that  representing  the  velocity 

.  The  exac.  .strength  of  this  can  be  '^"^"^ed  by  ascertaining  the 
strength  of  NaCl.  Nvhich  has  the  same  comluctivity  as  the  flu.c  to  be  tested, 
but  this  procedure  greatly  lengthens  the  t»me  occupied  m  the  determination 

"'  \"  For  other  temperatures  the  formula  from  which  the  above  is  derived 

would  need  alteration.  ,,,    .,^;.i:^,. 

-  The  electrodes  must  not  he  the  same  as  those  used  for  the  acuut> 
determination,  since  the  whole  of  the  O  or  the  H  cannot  again  be  removed, 
and  mistakes  will  occur  in  the  subsequent  use  of  the  apparatus. 


i'llYSKO-CMEMICAL  EXAMINATION 


133 


of  ferment-action  (Fig.  3)-  Comparison  of  the  two  formuhe  shows 
that  while  one  has  several  symbols,  representing  constants,  the 
other  has  similar  constants  expressed  in  figures.  The  rate  at 
which  a  fluid  alters  its  acidity  with  alteration  in  concentration 
follows  exactly  the  same  mathematical  law  as  does  the  chango 
of  reaction  produced  by  the  agency  of  a  ferment.  This  is  rather 
a  suggestive  fact. 

The  following  table  shows  some  of  the  results  obtained  by 
C.  Foi.  The  first  column  of  figures  gives  the  E.M.F.  of  the  gas 
chain  in  volts,  the  second  column  gives  the  value  obtained  for 
log  C„  from  this  tt,  and  the  third  column  gives  the  corresjKjnding 
value  of  the  concentration  of  H  ions  in  terms  of  10.  -  The 
remaining  colunms  are  added  ftr  comparison  of  the  ionic  acidity 
with  that  shown  by  titration  (in  terms  of  iwtash),  since  these 
values  are  more  familiar. 

Table  showing  some  of  the  results  that  have  been  obtained 
by  study  of  the  hydrogen  concentration  of  fluids  (Fo^). 


Keactior;     Indi- 
asKiven     cator 
by       I  uaeil  for 
Titra-   I    Titra- 
tion,        tion. 


Water 

Blood-scrum  (dog) 
Endocellular  Fluid 

Peritoneal  (horse) 
Pericardial  (horse) 
Cerebrospinal  (dog) 

Amniotic  Fluid  ... 

Aqueous   Humour 

( horse) 
Vitreous    Humour 

(horse) 

Bile  

Pancreatic  Juice... 


Urine  (human)... 


•«543 
■I5S3 
•1428 
•1362 

•1328 
•1299 
•1251 

•248 

•06 

•094 


-  742 > 9 
-74400 

-  7"34 

-  7«072 

-  7  049 

-  6  998 

-  69185 


9852 
3-785 

3681 

597 

7  8<3 

893 
1-005 

I2l8 


410,000 

n 
690,000 

n 
900,000 


KOH 


n 

"50 


1,000,000 
n 


HCl 

-90515  I  008882    -35^ KOH 

-  5  7820  I     16      i  _  „- HCl 

1 

-  6  3733  I    42-3 


n 
10 


litmus 


dimeihjl 

imido- 

azob. 


•081       —  6  1472 


2,500,000 

L        " 

i   1.000.000 

I  " 

6tx),ooo " 


HCl 


HCl 


M : 


SI 


134 


STIDIKS   IN    I'UNCTL'KE-FU'IDS 


The  most  conspicuous  result  of  this  kind  of  study  is  that 
practically  all  the  normal  fluids  are  at  the  neutral  point,  except 
the  secretions,  which  show  striking  deviations  fntm  the  rule. 
I'rine,  for  instance,  is  moderately  acid,  gastric  juice  is  markedly 
acid,  and  pancreatic  juice  is  markedly  alkaline.  The  fact  that 
in  nephritis  the  urine  shows  a  very  much  higher  degree  of  ionic 
acidity  is  not  only  of  interest,  hut  may  be  of  use  as  a  means  of 
clinical  pathological  research. 

Some  theoretical  considerations  on  the  reaction  of  hlootl- 
serum  which  have  heen  entered  into  by  HoIkt  deserve  notice 
here  in  relation  to  the  reaction  of  puncture-fluids.  The  electro- 
lytes which  occur  in  such  fluids  are  either  strong  acids  combined 
with  strong  bases,  or  consist  of  strong  bases  combineil  with  weak 
acids,  or,  htstly,  of  weak  bases  combined  with  strong  acids.  In  the 
first  cases,  hydrolysis  will  produce  an  acid  fluid,  and  in  the  other 
cases,  a  mi.xture  of  the  two  kinds  of  salt  in  varying  projxjrtions 
would  j)roduce  a  medium  which  was  either  alkaline  or  neutral. 
The  proteids  of  the  body-fluid  are  also  amphoteric  electrolytes, 
and  act  either  as  acids  or  as  bases,  according  to  circum- 
stances. Hober  has  pointed  out  that  it  is  a  great  advantage  to 
the  organism  to  have  these  various  groupings  of  acid  and  base, 
because  it  secures  a  }X)ssibility  of  addition  of  more  acid  or  more 
alkali  to  the  medium  without  any  corres}X)nding  risk  of  an  actually 
acid  or  alkaline  mediimi  being  produced.  This  he  illustrates 
by  the  following  consideration  :  su|)jK)se  that  the  fluid  contains 
Na^  CO3  and  NH,C1,  then,  when  dissociated,  there  will  be: 

Na  +  HCO,  H  +  .  OH   NH,  +  CI' 
HXO,  NH.OH 

H'  being  equal  to  OH  ,  Addition  of  a  strong  acid  will  prevent 
the  dissociation  of  the  Ho  CO;,  and  liberate  OH  "  by  acting  on  the 
anunonia,  so  that  the  fluid  will  remain  neutral.  The  more  weak 
acid  there  is,  and  the  more  free  weak  base  there  is,  the  more 
rapidly  will  the  addition  of  acid  or  alkali  be  prevented  from 
disturbing  the  equilibrium.  The  fact  that  according  to  Frieden- 
thal  70  times  as  much  soda  has  to  be  added  to  blood-serum  as 
to  water  in  order  to  produce  the  same  colour-change  with  phenol- 
phthalcin,  and  that  327  times  as  much  acid  has  to  be  added  to 
produce  the  same  colour-change  with  methyl  orange  shows  how 
great  the  adaptability  of  the  blood-serum  is  to  the  variations 


I'HYSUO-CHEMICAL   EXAMINATION 


135 


in  reaction  which  niifiht  \^c  pro.h.ca  by  disorders  of  metahohsni. 
and  of  course  the  sanu-  apphes  to  transudates  and  esl>eaatlY  lo 

exudates.  ,   , 

The  reflection  in  an  exudate  of  the  ,,hysi.-..-chemical  characters 
of  the  hlood-serun,  justifies  a  brief  reference  to  I'taundlcr's  work. 
He  showed  that  in  chiUhen  the  seiuin  is  practically  neutral, 
while  with  a.lvancinK  age  the  reaction  becomes  more  and  more 
alkaline  ;  on  the  ^ther  hand,  the  alkalinity  reaches  a  high  degree 
if  an  infant  suffer  from  chronic  nuti  itive  disease.  The  presence 
of  OH  is  necessary  to  many  of  the  phenomena  of  vital  processes  ; 
the  deficient  OH  content  of  the  blood  of  the  infant  nnist  there- 
fore have  some  relation  to  the  inactivity  of  their  ferments.  Again, 
the  fact  that  arterial  blood  is  much  richer  in  OH  *  throws  some 
light  on  the  function  which  the  trace  of  free  OH  plays  m  normal 
vital  processes 

The  results  of  Bc>nedicfs  study  of  the  OH  content  in  the 
blood  of  dialx:tes  lead  one  to  think  that  the  coma  of  dinlK>tes 
is  not  due  to  the  presence  of  acid  in  the  blood  so  much  as  to 
variations  in  the  equilibrium  mechanism  already  mentioned, 
while,  on  the  other  hand,  the  possibility  of  acid  being  masked  by 
this  mechanism  renders  it  difficult  to  draw  conclusions. 

D.  Viscosity.— Recent  months  have  witnessed  the  introduc 
tionof  anumber  of  new  forms  of  visco,imeter,  designed  to  i^rovidc 
the  clinician  with  a  tyin.  of  instrument  which  is  nmch  more  hamly 
and  easy  of  manipulation  than  that  hitherto  available  (Ostwald  s). 
Of  these  new  instruments,  it  is  proposed  to  describe  that  of  Hess 
as  from  practical  exiK^rience  it  has  lK.>en  found  to  fully  answer  a 
the  needs  of  the  clinician,  being  simple,  rapidly  used,  and  smp.ll 
in  bulk.  This  instrument  has  lx>en  employed  in  the  examination 
of  the  cases  in  the  Leeds  General  Infirmary. 

The  viscosimetcr  of  Hess  consists  of  two  capillary  tubes,  a  and 
c  (Fig.  9),  of  like  bore  and  length,  coupled  together  at  one  end  by 
a  T-tube,  e,  to  which  a  hard  indiarubber  ball,  g,  is  attached.  This 
ball  can  be  used  for  either  suction  or  expulsion  of  air  ;  by  means 
of  closing  the  hole  at  ^'  with  the  finger  ;  fluid  in  a  (water)  can  thus 
be  drawn  through  at  the  same  time  as  a  fluid  (the  materml  to  be 
tested)  in  c.  By  observing  the  distance  through  which  the  water 
has  passed  during  the  time  that  the  fluid  to  be  tested  passes  from 

•  Holder. 


136 


STUDIKS   IN    I'l'NCTURE-Kl.lIDS 


I 


om-  arbitrary  mark  to 
anotluT,  the  rate  ol 
flow  of  the  latter  is 
compared  with  that 
of  thi"  water. 

It  will  1h'  seen  from 
the   diagram   that  the 
(  apillary  tulH\  n,  leaiU 
into    a   wide   tuU-,    h. 
which  is  provided  with 
a  tap,  /,  before  it  joins 
the  T- piece.       In    the 
same  way  the  capillary 
tul)e,  f,  is  continuous 
with  a  wide  iuW\  d,  -i\ 
the  same  diameter  as 
/'.      This    tube,    how- 
ever, has  no  tap.     It 
will    also    1k'    noticed 
that   there   is  a   wide 
tube,  h,  joined   on   to 
the  capillary,  a.     This 
is  simjily    a  reservoir 
for  the  water  which  is 
used    for   comparison, 
and    is   undetachable. 
On  the  other  hand,  the 
tube,  h,  which  fits  on 
i  n     a     corresponding 
situation,     is     readily 
detachable,  and  is  used 
to   receive    the    fluids 
to    he    examined.      A 
large  number  of  these 
tulws      are      supplied 
with    the   instrument, 
so   that   a   new  clean 
one   can   be   used  for 
each  new  case. 

The     thermometer 


I'llVSlCO-t  IIIMICAL   KXAMINATION 


i}7 


serves  as  a  convetiu  iit  means  of  reatlitiR  the  temjHTAture  exartlv 
at  the  time  ot  the  .»l>sei  vation. 

Mcthoii  «f  /Vwf(/Mrf.— The  ammonia  which  hes  in  the  system. 
«rf.  is  exi)elle(l  by  the  use  of  the  l.ulh.  and  air  is  blown  thnnigh  for 
a  few  monx'nts,  in  oidti  to  thy  the  caiuilary.  The  stoju-ork,  /, 
is  now  oiKiif'<l,  and  tlie  }K»sition  ol  the  latter  colimin  adju-ited 
until  it  stands  at  zero.  Turning  od  the  lap  and  applying  the  tube. 
h  (( ontaining  the  tlui<l  to  In-  evamined),  to  the  free  end  of  tulu-,  t. 
taking  eare  that  no  air-bubl)!e  intervenes,  suction  is  applieil  imtil 
the  ct»luip.ii  ot  tins  fluid  is  on  the  zero  of  the  corresponding  scale. 

The  tap  is  once  more  ojiened,  and  the  two  fluids  drawn  on 
by  an  a))propi  iate  suction,  the  tuU-  d  being  carefully  watched  so 
as  to  st()|i  the  suction  as  soon  as  the  fluid  r«-aches  mark  I.  The 
reading  of  the  water  cohtmn  is  now  taken,  as  also  the  tempera- 
ture. If  desired,  the  fluid  may  now  Ix-  drawn  up  to  mark  2,  an<l 
a  second  reading  taken,  but  this  is  not  usually  necessary. 

This  done,  the  two  fluids  are  forced  back  till  the  water  is  once 
more  at  zero,  when  the  tap  is  turned  off  and  the  other  tube  is 
entirely  emptied.  Strong  ammonia  is  then  at  once  used  for 
washing  out  this  tulx',  and  unless  a  second  exi)eriment  is  alx)Ut  to 
be  undertaken  at  once,  some  clean  ammonia  is  left  in  the  tube. 

A  little  ex|)erience  with  the  instrument  would  soon  show  that 
unless  there  is  plenty  of  fluid  in  tul)e  h,  there  would  be  very  great 
risk  of  having  the  fluid  suddenly  shot  into  the  reservoir  r.  owing 
to  the  capillary  having  been  passed  before  the  advancing  edge 
of  the  fluid  has  reached  cither  mark.  The  capillary  must  be  full 
right  up  to  the  time  that  mark  i  or  even  mark  2  has  l)een  reacheil 
by  the  fluid.  To  ensure  this,  the  little  tubes,  A,  provided  should 
be  quite  filled  liefore  they  are  applied  to  the  free  end  of  capillary  c. 
It  is  essential  that  the  instrument  be  kept  scrupulously 
clean,  so  that  the  fluid  In'ing  examined  should  not  Imi  allowed 
to  remain  any  longer  within  the  tulx'  than  is  absolutely  neces- 
sary. It  is  also  advisable  to  clean  out  the  tulx;  occasionally 
by  the  aid  of  strong  nitric  acid. 

Other  precautions  needed  are  :  the  readings  must  be  taken 
with  the  eye  directly  over  the  meniscus  in  the  tube.  The  water 
should  be  replaced  from  time  to  time.  The  free  end  of  the 
tube  c  must  be  closed  with  the  indiarubber  cap  provided  when 
the  apparatus  is  not  in  uso.  The  stopcock  must  be  yently 
lubricated. 


138 


STUDIES   IN    rUN'CTURE-FLUIDS 


if 

i 


The  Theory  of  the  Instrument.*— When  a  fluid  travels  through 
a  narrow  glass  tube  the  jiarticle.s  which  are  nearest  the  glass 
move  more  slowly  than  do  the  particles  in  the  centre  of  the  flowing 
stream,  and  the  velocity  of  the  particles  will  be  greater  the  farther 
they  are  from  the  walls  of  the  tube.  The  effect  of  the  different 
velocities  of  thr  various  particles  according  to  their  jwsition 
within  the  stream  ol  fluid  is  that  the  more  slowly  moving  particles 
tend  to  retard  the  velocity  of  the  more  quickly  moving  particles 
next  to  them,  which,  however,  are  at  the  same  time  accelerated 
by  the  action  of  the  layer  still  more  internal  (which  is  moving 
still  faster).  Each  particle  of  fluid  is  under  two  forces,  one 
accelerating  and  one  retarding,  and  the  balance  of  the  two  forces 
is  shown  as  the  viscosity  of  the  fluid. 

If  the  fluiil  he  escaping  from  a  long  narrow  tube  of  radius  r 
and  length  1,  the  coefficient  of  velocity  v  will  be  given  by  the 
formula, 

wpr' 
"  =    SIV' 

where  V  is  the  volume  of  the  liquid  which  escajx^s  in  one  second 
of  time,  and  p  is  the  difference  of  pressure  between  the  two  ends 
of  the  tube. 

This  formula  affords  a  very  convenient  method  of  estimating 
the  viscosity  of  a  fluid,  for  in  Hess's  instrument  we  have  two 
tubes  of  given  length,  1,  and  of  given  radius,  r,  and  we  subject  the 
fluid  in  each  tube  to  the  same  pressure,  p,  during  a  constant  time. 
The  difference  in  coefficient  of  viscosity,  n,  in  the  case  of  water 
and  that  (.,')  in  the  case  of,  say,  ascitic  fluid  will  be  expressed  by 
the  ratio  : 


7 
>ii" 


irpr' 

8Tv" 

jrpr* 


V, 
V 


That  is  to  say,  the  volume  of  fluid  which  passes  through  the  tube 
containing  the  ascitic  fluid  is  to  the  volume  of  water  which  passes 
through  the  tulie  as  the  viscosity-coefficient  of  the  water  is  to 
that  of  the  ascitic  fluid.  In  the  instrument,  it  amounts  solely 
to  a  determination  of   the  volume  of   water  which  has  passed 

*  The  inventor  of  the  instrument  has  pubhshed  an  account  of  the 
theory  in  a  journal  unfortunately  inai-ct^iliie  to  nic.  tuil  it  is  not  tjiificult 
to  work  out  the  mathematics. 


PHYSICO-CHEMICAL   EXAMINATION 


139 


through  while  the  fluid  to  be  examined  passes  from  scale  mark 
o  to  I.  Taking  water  as  i,  we  now  know  the  fluid  visco.sity  of 
the  fluid  as  compared  with  the  water. 

If  we  refer  to  the  theory  of  the  ordinary  viscosimeters  which 
are  available,  we  find  that  the  vL:osity  is  measured  by  noting 
the  time  which  is  occupied  by  the  passage  of  a  given  quantity  of 
fluid  from  one  mark  to  the  other.  In  this  case  the  time  is  a  vari- 
able and  the  volume  a  constant.  However,  it  will  lie  admitted 
that  it  is  much  easier  to  measure  off  a  volume  than  it  is  to  measure 
off  so  many  seconds  or  fractions  of  a  second— which  necessitates 
the  possession  of  a  stop-watch. 

In  this  case  the  formula  becomes  : 


1    =    "»! 


St 

Mi 


where  r,  is  the  coefficient  of  friction  of  the  fluid  to  be  tested,  s 
is  its  specific  gravity,  rn  is  the  coefficient  of  friction  of  the  fluid 
with  which  it  is  to  be  compared,  and  s,  is  its  specific  gravity  ; 
t  and  t,  are  the  flowing  times  of  the  two  fluids  in  seconds.  Now, 
as  it  stands,  this  formula  demands  the  determination  of  the  sjiecific 
gravity  of  both  the  fluid  to  be  tested  and  a  standard  flu  and 
it  requires  a  knowledge  of  the  coefficient  of  viscosity  of  the 
standard  and  a  correct  observation  of  the  times  of  flow. 
Freshly  distilled  aniline  has  been  found  to  be  practically  equal 
in  viscosity  to  that  of  blood,  so  that  if  aniline  be  used, 

t       .       ■  t 

1}  =  I/,  -,  or  Ignoring  ij,,  t)  =  - 

which  means  that  one  is  always  comparing  the  fluid  with 
anilinp — a  very  artificial  standard. 

There  is  only  one  other  {wint  to  consider,  and  that  is  the 
influence  of  temperature  on  viscosity. 

Water  at  0°  C.  has  a  coefficient  of  viscosity  of  00178  eg  s.  units. 

Obviously  one  can  avoid  the  necessity  for  correction  for  tem- 
perature by  always  studying  the  viscosity  at  the  same  tempera- 
ture, as  could  be  arranged  by  the  use  of  a  water  or  air  bath.  But 
it  is  more  convenient  to  dispense  with  this  and  correct  for  results 
afterwards,  since  the  temperature  of  the  room  may  be  maintained 
correct  within  small  fluctuations. 


I40 


STUDIES   IN    rUNCTURE-FLUIUS 


\i 


On  the  other  hand,  water  will  not  be  influenced  by  tempera- 
ture to  the  same  extent  as  would  the  viscosity  of  a  fluid  such 
as  a  body  fluid.  Hess,  however,  made  out  from  a  number  of 
cxiieriments  that  there  is  not  a  greater  variation  than  4  per  cent, 
within  5=  above  or  below  17="  C.  Every  degree  difference  from 
jy^  requires  a  correction  of  08  per  cent. 

From  a  large  number  of  observations  published  by  Hess,  the 

blood  from  different  cases   showed  the  following  variations  in 

viscosity : 

Normal  Blood         5° 'o  S'4 

Chlorosis     ...         ...         ...         .••  4'4 

Carcinoma  Uteii 32 

Tubercle      4  9i-5"'5-5  4 

Pleiirisy       ...  ...  ...  •■•  S* 

Peritonitis  Traumat 5^ 

Tubercular  Meningitis  with  Coma  765 

The  following  table  (XIV.)  shows  the  results  of  examination 
of  various  puncture-fluids  by  this  method.  It  has  been  found 
that  the  higher  the  albumen-content,  the  higher  the  value  for  the 
\  iscosity.  so  that  in  exudates,  as  a  rule,  the  viscosity  is  greater 
than  in  transudates.  As  might  be  expected,  ovarian  cyst  fluids 
and  purulent  fluids  have  a  greater  viscosity. 

According  to  Rossi,  the  viscosity  of  blood-serum  runs  parallel 
with  the  conductivity.  Ascoli  came  to  think  that  the  variations 
of  conductivity  met  with  in  sera  of  different  degrees  of  alkalinity 
might  be  due  to  variations  in  the  viscosity  of  the  sera,  although 
an  assumption  of  formation  of  albumen-salt  compounds  would 
afford  a  more  satisfactory  explanation. 

Herz  found  that  the  viscosity  exerts  an  influence  on  the 
velocity  of  enzymatic  reactions,  and  that  the  velocity  of  reaction 
is  an  exponential  function  of  the  viscosity. 

An  application  of  the  use  of  viscosity  for  estimating  the 
amount  of  pepsin  has  been  referred  to  in  the  preceding  section. 

E.  Refractometry.— The  study  of  the  refractometric  charac- 
ters of  various  fluids  has  led  to  results  which  are  not  only  inte- 
resting but  of  value  in  the  differential  diagnosis  of  the  nature  of 
fluids.  The  appliances  necessary  for  the  work  are,  however, 
too  expensive  to  enable  the  method  to  be  widely  used.  Since  the 
subject  is  mainly  of  interest  in  the  differential  diagnosis  of 
exudates  from  transudates,  the  description  of  the  results  obtained 
has  been  placed  in  Section  IV. 


I'lIYSICO-CIIEMICAL   EXAMINATION 


141 


a 
5 


>      * 
-      H 

z 

W       p 

<       o 


O  *■♦ 
M  M  « 


'u  O 
3 

o  a)  n 

•5  E  E 

u  11  u 


p 


> 


s  E  E 
HUM 


:  e    : 

>.» 

3 
V 

en  o 

11  ; 
5-1; 


? 


>    01 


V   u 


._  ^  ^  _><: 

•5    3    3    2    U 
w«  —  ^—    SB    3 

s  ;5  ;5  ^  g 

•2-s-o 
'■H  3,2 
•5  «  «  ?=  '' 
<uuw 


J2. 


e 
« 
x 
If 


Jl. 


I 


« 


'C  J2  2  o 


ii  fc  t  c  >-  •-  "3 
<uu<ouo 


i2 


u 


a 

x 


n 


SECTION    III 

THE  CHARACTERS   POSSESSED   BY  VARIOUS 
PUNCTURE-FLUIDS 

Contents.— The  lymph— Pus— Pleural  fluids— Peritoneal  fluids— Opales- 
cent or  turbid  •■tfusions -Effect  of  repeated  tapping —Chyle — 
Pericardial  fluid  —  Synov  al  fluid  —  Hydrocele  fluid  —  Aqueous 
humour— Amniotic  fluid— Cerebrospinal  fluid— Cysts  :  ovarian,  pan- 
creatic, thyroid,  liver,  kidney,  spleen,  lymphatic,  lacteal,  parotid, 
bone,  spermatocele,  hydatid. 

Having  passed  in  review  the  main  methods  by  which  the 
analysis  of  puncture-fluids  may  be  accomphshed,  we  have  now 
to  describe  the  chemical  and  other  characters  of  each  of  the 
classes  of  fluid  which  may  be  met  with.  The  close  resemblance 
which  ordinary  lymph  bears  to  the  fluids  which  are  poured  out 
into  serous  cavities  as  a  result  of  back-pressure,  for  instance, 
renders  it  advisable  to  prelude  the  description  of  special  fluids 
by  one  of  the  main  characters  of  lymph,  in  so  far  as  they 
concern  us. 


THE   LYMPH 

This  alkaline  fluid  varies  considerably  in  composition  accord- 
ing to  the  part  of  the  body  from  which  it  is  collected  and  according 
to  the  state  of  nutrition,  besides  being  influenced  in  other  ways 
(blood-pressure,  digestion,  etc.).  We  are  chiefly  concerned  with 
the  amount  of  proteid,  and  perhaps  esjiecially  with  the  inor- 
ganic constituents.  An  analysis  by  Giibler  and  Ouevenne,  quoted 
by  Haniiiiaisien,  to  which  I  have  added  some  other  recorcfe, 
gives : 

142 


CHARACTERS  POSSESSED  BY  VARIOUS  I'UNCTURE-FLUIDS    1 43 


Water 

Solids:    ... 

Total  nitrogen 
Fibrin 

Albumen    ... 

Kat.  cholesterin,  lecithin.. 
Extractives:  xanthin.  hypo 
xsnthin,  guamin,  Icucin 
uric  acid,  tyrosin 

Salts  

NaCl 

Na.,CO,         

K.HPO,  

WPG.),       

Me,(PO,),      

FePO^ 


939"9   . 
6o-l         (may  drof  to  35  during  fasting*) 

012'  t 
05 
427        (albumen  :  globulin  =  2-4or4  :  1) 

.V8 


57 

7*3 

5-83 

2-17 

018 

028    jt 

009 

0025/ 


The  following  ratios  are   worthy  of  notice 


213:    I, 


NaCl 
PC)-, 


=1  10    22 :    I,    and 


carbonates 


XaCl        ^ 
achlorides 

:=  y8i  :    I,   as 


phosphates 

they  show  that  though  chlorides  are  abundant,  they  may 
not  be  very  much  in  excess  of  the  carbonates  or  achlorides, 
while  carbonates  are  the  most  conspicuous  of  the  achloride 
salts. 

The  gases  found  in  the  case  of  a  dog  J  amounted  to  37-4 
to  53  per  cent.  CO,.,  and  i-6  per  cent.  N  (at  N.T.P.),  the  CO^ 
being  mostly  "  fi.xed." 

The  other  constituents  of  lymph,  such  as  would  be  obtained 
in  puncture  of  the  legs  in  cases  of  dropsy,  are  apparently  similar 
to  those  of  the  serum,  and  will  vary  greatly  according  to  the 
disease  causing  the  drojisical  accumulation.  Thus,  the  specific 
gravity  varies  from  1005  to  loii,  the  amount  of  proteids  is 
generally  less  than  i  per  cent.,  and  is  less  in  cardiac  than 
in  renal  dropsies.  Blister  fluid  will  become  solid  on  boiling, 
however. 

The  /({/-content  rises  greatly  di-ring  starvation  (1-4  per  cent, 
instead  of  075  to  0-85). 

The  proteid-quotient  in  a  case  of  cardiac  dropsy  was  325,  and 
in  a  case  of  renal  dropsy  235  §.  The  globulin  is  increased  in 
renal  dronsy. 

Urea  is  often  fairly  abundant  (i  to  2  per  cent.). 

•  Munk  and  Rosenstein. 

t  Pickardt. 

;  liammarsten. 

§  From  analyses  made  by  Halliburton. 


144 


STL'niK.S   IN    PUNCTLRK-KLUIDS- 


1  ; 


The  oxmotic  concentration  of  such  a  fluid  varies  greatly,  being 
often  less  than  that  of  the  blood,  esi^cially  in  cases  of  cardiac 
disease,*  where  the  freezing-point  depression  is  0-54'  C,  while 
in  renal  cases,  as  one  would  expect  from  the  retained  salts,  the 
osmotic  concentration  is  greater  than  that  of  the  blood  (freezing- 
point  depression  =  0-57  C).  In  a  case  of  dropsy  due  to  cirrhosis 
of  tiie  liver,  the  fluid  from  the  legs  had  a  freezing-iwint 
depression  of  o'557'  C. 

The  nitrogen-content  of  dropsical  fluid  is  of  considerable 
interest.  esjH-cially  in  cases  of  renal  disease.  Estimation  of  the 
nitrogen  which  is  not  Ixjund  in  the  proteid  molecule  ("  filtration- 
nitrogen  "  of  V.  Noorden),  and  is  mainly  (80  jx-r  cent.)  comixised 
of  urea,  shows  that  there  is  a  relation  Ixitween  the  filtration- 
nitrogen  of  the  dropsical  fluids  and  that  of  the  blood,  and  that 
the  tiltration-nitrogen  in  renal  disease  is  much  greater  than 
that  of  health,  csi^cially  if  ur;emia  is  imix-nding  or  actually 
existent.  To  this  statement  the  ever-present  exceptions  will  be 
found,  and  unemic  cases  may  show  no  unusual  amount  of 
flltration-nitrogen.  However,  the  general  rule  is  to  And  an 
excess  of  this  nitrogen  stored  in  the  tissues,  and  in  a  case  of 
chronic  nephritis  v.  Noorden  found  the  following  daily 
variations  : 


KlLTRATION-NlTROCFN    IN    ReNAU   DISEASE 


\M.t. 

June 

36 

,, 

27 

July 

23 

n 

24 

Aug. 

2b 

Sept.  27 

Right  Ug. 


Left  Leg. 


0-0928% 

0084% 

00897 

00792 

00716 

o"07io 

00144 

... 

00748 

... 

Remark*. 


Urtemia 


and  that  as  much  as  70  grams  of  nitrogen  could  l)e  stored  up  in 
the  dropsical  fluid  within  five  days,  so  that  the  subcutaneous 
tissues  form  a  very  effective  depository  for  waste  nitrogen. f 
Such  a  change  would  escape  a  cryoscopic  and  filtration-nitrogen 


♦  Z,ingemfisttT. 

f  Ktifience  to  ihcse  observations  is  made  in  order  to  draw  attention 
lo  the  relation  between  the  subject  of  this  work  and  the  study  of 
mctabohsni. 


CHARACTERS  POSSESSED  BY  VARIOUS  PUNCTURE-FLUIDS    I4S 


determination  of  the  blood,  anil 
account  in  part  for  erroneous 
results  in  diagnosis  of  functional 
renal  disease  by  the  cryoscopic 
method. 

We  may  therefore  find  much 
urea,  uric  acid,*  and  chlorides 
stored  up  in  dropsical  fluids  of 
nephritis,  and  glucose  may  also 
occur  to  the  extent  of  005 
to  015  per  cent,  (apart  from 
diabetes). 

Electrochemical  examination  of 
lymph  shows  that  it  has  a  slightly 
acid  reaction  : 


•0729 


log  Cii 
—  6'oo65 


Ch  X  lu 

<)8-52 


The  special  observations  shown 
in  the  table  on  this  page,  have 
been  made  on  cases  in  the  Leeds 
General  Infirmary'. 


PUS 

The  chemistry  of  pus  affords 
an  explanation  of  the  properties 
of  certain  exudations ;  the  physical 
properties  need  no  comment. 
When  pus  has  an  acid  reaction, 
this  may  be  ascribed  to  the 
presence  of  lactic  or  of  glycero- 
phosphoric  acid. 

Hoppe-Seyler  gives  the  com- 
position of  pus-cells,  and  I  have 
added  marginal  notes  from  other 
authors. 

♦  "006  to  "009  per  cent.  (Pickardt). 


:=  I  > 


^ 5  21- > 


« 

u^ 

0 

0 

I 

I 

8 

M 

•58 


^ 


T  u  > 


!J  = 


5-° 


08.2 

S 


siiv 


•a  e  c   .    ■ 

■*•  QJS     ."" 


% 

001 1 

in 

QO 

s 

0 

3> 

r^ 

s 

00 

QO 

? 

3 

o 

m 
Z, 


•5  > 
.b  .  ^ 
U    :     ■-. 

o 

■&  .2 

•5  .  I 
ii      ^ 

8       u 

s  c 

Si  £ 
e  :    < 

c 


I  -       E 

:2v,    :s 


10 


146 


STUDIES  IN   PUNCTURE-FLUIDS 


Prolfids 


i 


137  /'=  (mostly  iiiKlco-albumcn;  aUo  albutnosc,  peptone 
arid  fibrin  ferment  *) 


(also  pyosin  and  pyofsenin  f) 
(xanthin  bodies;  leucin  J) 


Nuckin      34'i6 

Insoluble  substance  2056 

Lecitliin     7'5 

Kats  and  soaps     ...     75 
Cholcstcrin  ...     7'4 

Cerrbrin     ...  ...      S'^ 

Kxtractives  ...     44 

<;iycogcn  in  living  pus-cells 
Salts     Miesdicr  gives : 

Potassium  phosphate         

Sodium  phospliatc 

Earthy  phosphates  and  iron  phosphate 

NaCl         

Organic  phosphates       


61  ,< 

42 

1-4  • 

314  to  203  , 


parts 


As  bearing  on  the  differential  test  fully  described  in  Section 
IV.,  attention  may  l>e  directed  to  the  salts  of  pus-cells.§     The 

ratio  of  chlorides  to  achlorides  is  ^^=-"  ^  ■  ^^'  ^^^  ^^^  P°^^" 
slum  salts  forms  by  far  the  larger  projwrtion  of  the  achlorides. 
The  exact  composition  varies,  however. 

In  tuberculous  abscesses  there  will  be  found  leucin,  tyrosin, 
free  fatty  acids,  volatile  fatty  acids  (formic,  butyric,  and  valeri- 
anic), and  urea. 

The  serum  of  pus  is  similar  to  that  of  the  blood,  though  its 
relative  bulk,  as  compared  with  the  volume  occupied  by  the 
pus-cells,  is  small ;  the  result  is  that  the  composition  of  the  latter 
will  have  much  influence  on  the  total  composition  of  the  pus. 

Hoppe-Seyler  gives  : 


Water     

Solids      

Organic  solids   ... 

Proteids 

Lecithin  

Other  organic  matters... 
Inorganic  salts  ... 
NaCl       


9«37  -9056 
863   -  94-35 
78-57  -  86-58 
62-23—  7721  ^NaCl 


15  —  056 

14-84—  8-8i 

2-51—  2-38 

5-22—  5"39 


Na.SO, 

NaiHPO, 

Na.;cO, 

Ca,(P6,)., 

Mg,(PO,), 


5-22 
0-40 
0-98 
0-49 
049 
6-19 


The  amount  of  lecithin  may  be  noted,  in  reference  to  its 
appearing  in  certain  inflammatory  effusions. 

♦  Halliburton. 

•f  Kossel  and  Frcytag. 

X  Friinkel. 

§  I  am  indebted  to  Prof.  B.  Moore  for  directing  my  attention  to  the 
composition  of  the  inflammatory  cells,  which  will  explain  the  electrolytic 
character  of  exudates  as  compared  with  transudates  (Section  IV.). 


CIIARACTKRS  I'OSSESSED  I!Y  VARIOUS  PUNCTURE-FLUIDS    I47 


chlorides  _  ^  .  ... 
The  salt  ratios  may  again  be  referred  to  :  ^^^^^  ^^^^  —  i .  i  4. 

carbonates  _  chlorides    ^  ^ 

chlorides    ~  ^  "  ^°  7  achlorides        -  •    • 

The  pigments  in  pus  are  separable  by  ether  and  are  due  to 
micro-organisms.  Crystalline  pigments  are  met  with,  and  also  a 
yellow  pigment  (pyoxanthin).* 

The  osmotic  concentration  is  usually  high,  being  consider- 
ably above  that  of  the  blood.  In  a  case  of  pyopneumothorax, 
for  instance,  I  found  a  freczing-iwint  depression  of  0867  (osmotic 
concentration  o^bS),  and  in  the  accompanying  list  are  observa- 
tions by  Zangemeister,  who  noticed  that  bacterial  growth  in- 
creases the  osmotic  concentratioii.t  This  would  satisfactorily 
explain  the  high  concentration  of  pus.  Sterile  pus  will  be 
isotonic  with  the  blood,  v.  Rzentkowski,  however,  attributed 
the  high  freezing- jxiint  depression  to  the  presence  of  the  pus- 
cells. 

Osmotic  Concentration  of  Pus 


Nature  of  Caie. 

KreeziofC-point 
Depretiion. 

()$molie 
ConctnlrmtioH.* 

I'reMure  in 
Atmoapbercr.* 

Pneumonic  Empyema 

•684^ 

•369 

8-2 

Tubercular          , 

■828 

■447 

99 

„             (three  other  cases) 

•840 

■454 

lo-i 

Psoas  Abscess 

•539 

290 

•580 

■^'1 

t' 

Puerperal  Peritonitis 

■642 

•346 

77 

Mastitis             

•586 

■316 

70 

„        (reccnfabscess) 

•709 

■383       ^ 

8*5 

Empyema  (Herzfeld) 

•47  and  -55 

•254  and  297 

56  and  6 6 

•  These  valuea  are  my  own. 

A  cai,e  of  empyema  +  examined  gave  the  following  results  : 
specific  gravity  1025,  albumen  3  jwr  cent.,  chlorides  14  per  cent., 
concentration  of  electrolytes  092,  of  achlorides  068.  Globulin 
was  abundant.  Urea  and  glucosamin  were  not  found.  The 
ferment-content  is  recorded  in  another  place. 

In  another  case  of  empyema  which  was  e.\amined.§  the  fluid 
contained  2*45  per  cent,  chlorides,  8  per  cent,  proteid,  and  had  a 

•  Fordos  and  Liicke. 

t  Herzfeld  denies  that  the  molecular  concentration  is  usually  increased 
by  Bacilli  coli.  staph vlococci.  or  Racilli  tuberculosis. 
I  Register  No.  7334  (Leeds  General  Iiitirmary). 
§  Reg.  No.  8349. 


'l 

If 

'1 
1 

!i 

i 

i 

! 

I4K 


STlItllS   IN    ILNCTUKK-FLLIDS 


s|HTific  Kiavity  c»f  loj-'.  I'm-a  wiis  present  in  large  amount,  but 
purins  could  not  Ik-  found.  l>rot;ili)umosc  and  hetero-albumose 
were  present.  Tlu'  tryptopluuv  and  Klurosamin  radicles  were 
not  identified. 

PLEURAL  AND  PERITONEAL  FLUIDS 
The  similarity  in  the  physical  and  chemical  characters  of 
these  two  fluids  will  make  it  more  convenient  to  consider  them 
together.  Those  pro|xrties,  which  enable  the  pleural  and  peri- 
toneal exudates  to  be  distinguished  from  the  transudates,  will 
be  found  dealt  with  fully  in  Section  IV'. 

These  fluids  are  generally  alkaline  and  of  straw-yellow  colour. 
The  brown-stained  fluids  usually  owe  this  character  to  the 
presence  of  blood,  but  in  some  cases  h.-emoglobin-colouring  is 
met  with  (familiar  in  tuberculous  and  carcinomatous  effusions). 
An  intensely  blood-staineil  fluid  was  recently  met  with  in  a 
purely  cardiac  case.* 

Pleural  fluids  from  cases  of  new-growths  of  the  pleura  are 
well  known  to  Iw  frequently  ha;morrhagic,  and  they  may  become 
darker  in  colour  the  more  frequently  they  are  tapjied— up  to  a 
certain  point,  after  which  they  become  paler  t  (see  also  the 
cytological  characters  of  these  fluids.  Section  V.).  Probably 
this  phenomenon  is  due  to  the  relief  of  tension  on  the  delicate 
tumour  vessels. 

Sometimes  there  is  a  }K'culiar  opalescence,  or  even  actual 
milkiness,  a  feature  which  calls  for  special  consideration. 

The  odour  and  colour  of  a  fluid  give  some  indication  as  to  the 
bacterial  infection  in  a  given  case  of  [x-ritonitis. 

We  may  compare  the  comjiosition  of  pleural  with  that  of 
peritoneal  fluids  (transudates). 


Pleural 
(C.  Schmidt). 


t'crituneal 
(Hoppe-Seyler). 


Water 

Solids 


^  ...     fProteids 

Organic   solids  ^g^tractiv, 

Inorganic  solids 

Sugar     

Uric  acid 


966-24 

1   952-9^ 

3376 

■     4638 

es  / 

2682 

349 
,       428 

764 

7-2 

005:: 

* 

present 

OGOI 

5%* 

•0013 

•  l>ick»rdt. 

*fo.  1017 

3- 

t    V. 

Starck. 

-•co78%« 


CIIAKACTEUS  POSSESSKD  I!Y  VARIOUS  P'TNCn'UE-KI.UIDS    I49 


Anal>-ses  which  have  lieen  made  by  thf  same  authorities 
show  that  the  different  effusion*  met  with  in  .1  tjivcn  case  ol 
Bright's  disease  may  show  slight  (hffereni.  -,  in  chemical  lom- 
|)osition.  The  most  striking  jK)int  alx)ut  the  analyses  which  are 
obtainable  is  the  absolutely  i'  itorm  salt-content  in  each  fluid 
(pleural.  j)eritoneal,  udeina).  The  proteids  are.  as  one  would 
exjx'ct,  uniformly  less  in  the  dropsical  fluiil,  ami  the  water  is 
always  greater  in  that  Huid  than  in  the  case  of  the  |)leural  anil 
jKTitoneal  effusion.  The  pleural  fluid  usually  contain-  the 
largest  percentage  of  proteid  and  the  least  w.ifer.  The  varia- 
tions, then,  are  mainly  in  the  organic  constituents. 

From  analyses  of  various  pli-ural  tiiiuls  ntonltd  hy  llallilmrtoii  »t 
is  sii'n  that  acute  plt-iirisits  havo  a  specific  Rravity  of  more  than  taio. 
while  the  hytlrothorax  ftuids  (whether  renal  or  tarJiac)  are  U.nv,  1020. 
The  total  proteid  is  <  to  5  percent,  in  the  pleurisies,  and  only  1  01  i  in  the 
transudates.  The  proteid-quotimt  shows  that  Kluhulin  may  1  more 
abundant  in  exudates,  while  it  is  practically  always  less  111  amount  than 
albumen  {proteid-ipiotient   ii  to  i  •>)  in  transiulates 

Globulins.— In   three   different  sj)ecimens  of   .iscitic   fluid, 
Freund  and  Joachim  found  the  following  globulins  : 


Peritoneal  Fluid.       EuKlobulin. 


I'leurio- 
globulin. 


I'ara- 
glohulin. 


Parupseudo- 
Itlotiulin, 


Nuclro- 
globulin. 


Cirrhosis  of  Liver 
Carcinoma     i. 


Trace 

Trace 

Merest  trace 


+  + 

+         I  Small  amount 
Moderate  i  Trace 

amount 


Associated  with  the  globulin,  there  may  be  a  considerable 
quantity  of  lecithin*  as  we  shall  have  to  refer  to  tully  presently 
when  dealing  with  the  cause  of  opalescence  of  puncture-fluids. 
The  presence  of  globulins  in  excess  in  exudates  will  have  a  physio- 
logical value,  since  the  association — in  some  unknown  way — 
of  globulin  with  antibodies  will  serve  to  protect  or  help  to 
protect  a  patient  from  the  dangers  of  bacterial  peritonitis,  for 
instance. 

Aminoacids  have  been  described  as  occurring  even  to  the 
extent  of  0062  per  cent,  in  cases  of  jx^ritoneal  effusion  associated 
with  Banti's  disease.  Glycocoll  was  found  amongst  them. 
Considering  how  difficult  it  is  to  reach  a  high  degree  of  accuracy 
in  the  estimations  when  jO  [>er  cent,  or  more  of  ieucin  may  escape 

♦  Jolies,  Joachim.     See  also  page  159- 


i« 


,50  STri)IK>   IN    lUNtTlUK-ILni'S 

„,  „u-  ,>HKe>s  ot  quantmuiv.  .nah-sis.  w.  ,n.v  .onclucle  that 
I  nua„..tv  ..I  ain.n...u..ls  .nay  U-  .n.uh  ^u-ator  than  ..  c^..;- 
UunHvl  tv-..M„  ..nu.  .n  ,K.r..on.al  tUu.!  meases  of  c,rrh...s 
„|  thf  liv.r,  Mcnrdma  to  Hanunarsten. 

K,.sn>.  u  N.rK.K.KN.  Th.s  .s  ,..lat,v.ly  h.^h  m  transudates 
t.277).  as  Will  as  W■^n^^  al.solutfly  mcirascl.  28.5  g.u 

AMM..MA.-M".v  than  .,  n^K.  i>.-r  cent,  was  met  with  m  a 
rise  of  cirrhosis  of  the  liver. + 

HHSC  F-JoNKS  PKOTB.n.-The  presence  ol  th.s  substance  has 
iH-en  desn.lH.1  by  HUmKer  as  occurring  m  the  ascitic  tlu.d  m  a 
case  of  multiple  myeloma  of  the  bones.J 

"  SvCAH^.-DcMrosc  has  been  .K-scribed  as  occurrinR   in   the 
ascitic  fluid  in  a  case  of  renal  disease. 

Frnclosc  §  api^ars  in  ascitic  fluid  in  cases  of  carcinoma  and 
,n  some  cases  of  granular  kidney,  if  pven  by  the  mouth.  It 
was  found  m  pleural  fluid  in  cases  of  nuiU.ple  lymphoma  though 
Tl  vulose  L  given  by  the  mouth.  I'lckardt  states  that  the 
otal  leducmg  substance  in  ascitic  fluid  -V  amount  to  o...  p^^r 
cent  The  following  table  of  analyses  made  by  P.ckardt  will 
Illustrate  the  variations  in  composition  which  may  be  met  with  . 


Diieaie 


%N. 


■*>  ■>     *A    J   1  RoUtion      Riducinit 

Albumen.  1  t'ric  AciO.  !  Substance. 


014 

087 

0C036 

046 

2S75 

trace 

022 

'■375 

., 

059 

.V69 

00048 

1    o<'5 

406 

0003 

0906 

5-663 

00025 

0188 

1175 

009 

0563 

OC06 

(lextro- 

ISEVO- 

0084 
0070 
0106 

dcxtro- 

0029 

l.vvo- 

,    dcxtro- 

It 

0050 
0113 

Cirrhrsis  of  Liver 

I  Carcinoma  o(  Peritoneum 
VrubircuUr  Peritonitis    ... 

Pleurisy     ... 

Nephritic  CKdc  ma 

Cardiac  Failure  (,(i:dema) 

*   Friclnchsen,   Vages,  and   Husches. 

'   ^;oS"tins  substanco  has  been  known  for  nearly  s.xty  ycars^.ts 

"r'Lu.  .n,[  conlam,  mUhcr  glycocoll   nor  pl.o.pl.o. „,. 

3.  It  is  not  soluble  in  (rf.  per  cent,  alcohol. 
§  Ncuburger  and  Strauss. 


CHARACTERS  KkSSESSKD  |,Y  VARIOUS  PUNCTURE-FLUIDS    IS" 

Reference  to  the  nitroRcn  an.l  albiunen  jK-rcentaRc  will  show 
the  striking  (act  that  .(  the  ,x.r.toneal  cav.ty  contain  lo  htrc. 
„(  fluid  at  i  to  4  IH-r  cent,  of  alUnnen.  there  w.U  then  »>e  625  o 
1..50  granunes  of  proteicl-equ.valent  to  n.ore  than  z  lH,uncl» 
of  meat-within  the  jicritoneal  cavity ! 

In  serous  fluuls  tl»e  dry  matter  and  total  nitrogen  are.  as  one 
would  exiK-ct.  less  than  in  the  blood-serum,  but  the  numlx^r  oi 
extractives  is  still  U-ss  than  those  in  the  serum.* 

Ali-ANToin  has  l)een  found  in  the  transudate  in  a  case  of 

cirrhosis  of  the  liver.t 

^lj^^^.,ss.-"Serosamucin"  occurs  in  certain  exudates.     Tht 

subject  is  dealt  with  in  Section  I. 

PiGMENTS.-Bile-pigment  and  urobilin  may  occur.      There 
may  be  an  undue  quantity  of  uric  acid  associated  with  urobilin. 

A  s.>«.al  nutho.1  of  stu.lv  of  l.o.ly  flui.ls  was  .lcvis«l  by  I^mlolf,  which 
is  o^rreu-lt  though  somewhat  com,,hcat..l.  The  .loscr.pt.on  of  he 
ItLT*  .^-  not  seen,  compUt...  Th.  total  prot.ul  h  t.rst  en  .mate.1 
bv  KT'uiah^sinK,  an.l  hv-lrolys.s  .h  th.-n  carncM  out  by  means  of  strong 
hldSch^ric  aci'l .  After  hvdrolys.s.  polar.metr.c  obseTvat.ons  are  ma.le 
a  1"°;  the  Uevo-rotat,onof  peptone,  wh.ch  may  be  present  m  thef^nal 
flu°r  This  author  d.scusses  (,.)  the  rat.o  of  the  insoh-ble  albumens  to 
fhe  leJc'  of  rotafon  of  the  hy.lrolyse.1  ftu.cl.  (/.)  the  rat.o  of  the  mso  uble 
.  \:lX\Z\\e^  after  hy.lrolys.s  to  the  total  nitrogen  of  the  hydrolyscd 
r^M  tL^Uo  ofth    rotaton  of  this  fluul  to  the  total  mtrogen.  (d) 

S:„tr^.rrtherc;^c;:s'Liel  Lt.mat.l  ...ect,y,  p.. 
.  V^!.„  nf  ffie  filtrate  alter  .stimating  these  nitrogenous  boihes. 
tLc  ch  e  t.su It   o     tlu-sc    laborious   researches   .s    to   show  that    the 
albumL  of  puncture-fluids  is  much  more  res.stant  to  hydrochlor.c  acid 

^'^Tht  f^EnTanalyses  are  selected  from  Lando.fs  paper  : 


Fluid. 


Albumen 

% 


Dry 
Reiiaue 


Pleural 


Abdominal*  I 


5861 
0947 
403 
217 


6896 
1832 
509 
347 


Aih.       Urea% 


NaCl  % 


Re<>uc- 
ing  Siib- 
■tancc. 


inaolubl* 
Albumen 
other  tC. 


Fat. 


0844 

0-55 

058 

0-I02 

25:1 

0804 

0-62 

002 

1:3 

087 

... 

056 

0-3 

... 

084 

0-57 

oa4 

•  •• 

0-62 
090 


■  Opalescent. 


•  Rzentkowski. 
^  V.   Jaksch. 


Biochcm.  Zeit.,  vi.  61. 


152 


STUniKS   IN    PUNCTURE-FLUIDS 


m 


INORGXMC  CoNSTiTrENTs.-Chlorine  is  retained  in  the 
peritoneal  fluid,  not  only  in  nephritis,  but  also  in  other  conditions, 
such  as  hepatic  or  cardiac  l)ack-j>ressurc. 

While  a  peritoneal  fluid  is  accumulating  the  salts  will 
increase  in  amount  :  CI.  N.  and  P,  come  to  be  retained,  showing 
a  deficient  ixjwer  in  the  organism  of  disassimilation.  On  the 
other  hand,  if  the  fluid  is  undergoing  absorption  these  elements 
are  excreted  in  considerable  quantity,  and  there  is  P-  and  Cl-loss. 
If  the  nitrogen  of  the  food  docs  not  meet  the  demand,  the 
albumen  of  the  tissues  comes  to  l>e  attacked.* 

Gases. -Transudates  contain  CO,  and  traces  of  nitrogen  and 
oxygin.  Tlie  tension  of  the  CO,  is  greater  than  that  of  blood 
in  transudates,  esi)eciallv  if  pus  is  present  (Hammarsten). 

Physico-chemic.m  FE.XTfRES.— As  compared  with  the  blood, 
the  physico-chemical  characters  are  usually  found  similar.f  though 
the   concentration   of   the   non-electrolytes   is   hardly  ever   the 

same  in  the  two  rases. 

Osmotic  Concentration.-This  has  been  studied  by  various 
observers,  with  a  view  to  the  detection  of  the  nature  of  an  effusion, 
and  in  the  hope  that  prognostic  indications  might  be  obtainable. 
Thus  it  has  been  said  that  the  lower  the  osmotic  pressure  as 
compared  with  the  blood,  the  more  likely  is  the  fluid  to  become 
absorbed;*  but  this  is  disputed  by  Herzfeld.  who  holds  that 
absorption  does  not  depend  on  the  osmotic  pressure.  From 
personal  observations  one  is  inclined  to  agree  with  Herzfeld.  but 
it  is  diflicult  to  be  dogmatic  on  such  a  jwint,  and  it  is  most  likely 
that  the  factors  influencing  absorption  are  more  comi)licated. 

Rzentko-  ,ki  thought  that  tuberculous  pleural  exudates  have 
generally  a  much  higher  osmotic  concentration  than  the  blood, 
e*l)ecialiy  if  there  be  pus  present.  But  this  observation,  which 
raised  a  hope  that  tuberculous  pleurisy  could  be  readily  diagnosed 
from  the  cryoscopic  examination,  was  soon  found  to  be  faulty. 

The  value  of  the  determination  of  the  osmotic  concentration 
of  an  ascitic  or  pleural  fluid  has  Iwen  stated  to  lie  in  the  deter- 


if  that  is  increasing, 
the  fluid  may  be  said  to  lie  increasing  in  amount. 


mination  of  the  ratio  ^.,^^-j  of  the  urim' 


*  Marischlcr  and  Ozarkiewicz. 

t  BckIou. 

J  Kctlcy  and  Torday. 


CHARACTERS  POSSESSED  BY  VARIOUS  PUNCTURE-FLUIDS    153 


~       'J0|q3«  'D 


|HII|^|:pf;^;f|i?PH?i  ilB^f  1 


•p»i»  0      2 


-XtiAiianp 
-U03 


o 


^  ro       r^  o^  t'i  ^  O^ 


%'Mn 


•JO  ds 


i§2222§  -^^^i  -22222222222  2  2_2  2  = 


^ 


M 

.  o 
•  ** 
■X 


eS 


E 

E 
••2  2 

"c  .2  ^ 


.^    t-    u 


!/)H 


c    :    : 
o    ■    • 

E 

3    l- 

S'S.-s 
£2a: 


■s'^    Ui 


B    O 


"3  o 

c  = 
u  o 


.2  S 

*-   > 

X  .2 

?.-£ 

•o.i: 


i.  o 


■C    IT    g    ' 


'^  fc  u 
u  V  J; 


.2  c 

•ss 


«    fi.  '^  u-  J9    ._    -    « 


I  g-2'^1.2.2  gt 


S"''-  ESS  §  s  g  s 


>w^5;«  iT-fi.  .-:;£;  t-:r^s,j;;  5;  S- 


30  00  i~»  JO  oe  oe  00 

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l89UO)U3({ 


154 


STUDIKS   IN    I'UNCTURE-t'LUIDS 


m 


The  following  table  (XVI.)  shows  the  observations  which 
have  been  made  on  cases  in  this  hospital  : 

lAHl.K  XVI 

OsMori.     CONCFNTRATION    OF    Pl-FURAL    ANI.   PERITONEAL    KlUIDS 


Nature  of  Cise. 


Kreeiing- 

point 

Depression. 


Osmotic 
Concen- 
tration. 


Pressure 
in  Atmo- 
spheres. 


u: 


Tubirciilons  I»critonitis      

fari-inomatous  „  (stomach  I 
Chronic  Peritonitis  (gastric  iilccn... 
Carciiioiiuitmis  Peritonitis 

lubcrcular  Peritonitis 
Siippiiralive      Tuberculous      Peri- 
tonitis 
Thrombosis  of  Portal  Vein 
Cardiac  Kailure         

Multilobular  Cirrhosis         

Cardiac  Failure        

and    Cirrhosis    ol 
I.ivcr     ... 

Renal  Asciti;s  

Cirrhosis  of  I, iver 

Cirrhosis  of  1-iver 


C  hronlc 
nitis  . 


Pcrito- 


Cariliac  Failure 
Renal  Ascites 
Acute  Nephritis 
V  Interstitial  Nephritis 


•569 

520 

752 
064 
•569 

■595 
•667 
•576 
•566 
.649 

574 

•750* 

•667 

■55» 
•667 

•544 
■586 
672' 
•676* 

•75' 


Tuberculous  Pleurisy 

Simple  Pleurisy 
lubereulou^  Pleurisy 


-56.? 

488 

-549 

-56^ 

-552 

•320 

Markedly  hypei  tonic 


•299 

•274 
■406 

■35« 
■307 

.?«3 
360 
•310 

•298 
■34' 

•^02 

•395 
•360 
301 
■360 

•294 
310 
361 

364 
•405 


■303 
•257 
297 

•298 
297 


683 

6-24 
90 
80 
6-8 

7«3 
80 
69 
680 

778 

689 

90 

80 

6-7 

80 

65 
70 
80 
81 
90 

6-7» 

586 

66 

6-7 

66 

6-6 


The  molecular  concentration  is  thus  seen  to  vary  very 
greatlv  and  to  be.  as  a  rule,  much  more  marked  in  iieritoneal 
than  m  pleural  fluids,  and.  as  a  rule,  greater  m  transudates  than 

in  exudates.  .     ..•        ■     *u« 

In  nephritic   transudates   the  osmotic  concentration  is  the 

same  as   or  a  little  less  than,  that  of  the  blood  of  the  patient. 
The 'chlorine   retention    which    occurs    in    transudates   will 

explain   this  feature   in   part.     The  reference   which   has   l>een 

made  to  the  other  constituents  in  transudates  affords  additional 

information. 


CHARACTERS  POSSESSED  HY  VARIOUS  PUNCTURE-FLUIDS    I  55 

As  regards  the  eledro-conduclmty  and  the  concentration  of 
the  electrolytes,  both  chloride  and  achloride,  reference  need  no 
here  be  made,  as  the  application  of  this  method  to  diagnostic 
purposes  is  gone  into  at  length  m  the  following  section.  Some 
experiments  of  Sasaki  may.  however,  be  referred  to,  m  whi  h  a 
nerhritis  was  artificially  induced  in  rabbits,  with  a  resulting 
decided   increase   in   the  electrolyte-content   of   tbe   peritoneal 

"^"^  Concentration  of  Hydrogen-Ions.-The  concentration  of 
the  hydrogen-ions  in  ascitic  fluid  has  not  been  frequently 
determined      The  reader  may  be  referred  back  to  the  table  in 

^''fermfnts.  Antifermests.  and  Toxins. -The  ferment- 
content"  of  various  fluids  has  been  discussed  on  a  preceding 
page  where  the  results  of  one's  own  observations  are  tabu- 
Led  These  observations  may  be  amplified  by  a  reference  to 
Marshall's  work,  ^ho  found  that  both  pleural  and  peritoneal 
fluids  have  the  power  of  ha.molysing  blood  other  than  human 
nig  rat  or  goose  blood,  a  fact  which  goes  to  show  that  these 
flui'ds  contain  complements  which  can  activate  various  ambu- 

''^TlTe  content  in  complement  of  some  fluids  for  a  given  lysin 
varies  independently  of   the  content  in  complement   for  other 

lysins.  ,  ^ 

Fibrin-ferment  is  frequently  present  m  exudates. 

The  ascitic  fluid  in    carcinomatous  cases  is  hemolytic,  just 
as  the  extract  of  these  tumours  possesses  a  lu-emolytic  power. 

ANTIFERMENTS.-Muller  found  that  the  amount  of  anti- 
ferment  rises  with  the  albumen-content  and  vaiiesin  amount 
whTthe  degree  of  destruction  of  the  leucocytes.  The  following 
results  were  obtained:  


Ca«r. 


Antiferment-Content. 


Asiites  due  to  passive  cc  ngestion 

Hydrolhorax 

Hydrocele 

Pure  lubt rcular  I'critonitis 

Acute  Peritonitis 


In  excess 


Lessened 
Lost 


Antiferments  to  congenital  syphilis  have  been  found  in  the 
peritoneal  fluid  in  three  cases  by  Hans  Bab. 


156 


STLDIKS   IN    I'UNCTLKE-KLUIDS 


Autolytic-U'.aents  are  said  not  to  occur  in  puncture-fluids.* 

PoiSONOrS   hlFECT  OF   ExrUAi'^S  AND  TRANSfDATES  WHEN 

iNjErTED  INTO  THE  Bi.ooD.— In  cirrhosis  of  the  liver  the  transu- 
date is  no  more  poisonous  than  the  effusion  in  pleurisy,  showing 
that  the  jrortal  l>lood  is  not  more  toxic  than  the  blood  of  the 
general   circulation. 


«•. 


THE  EFFECT  OF  REPEATED  TAPPING  ON  THE 
COMPOSITION  OF  PLEURAL  AND  PERITONEAL  FLUIDS 

That  a  chalice  in  comiHisition  resulted  from  repeated  tapping 
was  notetl  by  Halliburton  and  discussed  by  him  in  some  detail. 
He  found  that  the  total  proteid  first  rises  in  amount  and  tinalh 
falls,  the  globulin-content  increasing  more  than  the  albumen. 
This  increase  in  amount  of  jiroteid  is  very  frequently  noticed, 
though  it  is  not  an  invariable  rule,  since  in  an  analysis  of  peri- 
toneal fluid  by  Hoppe-Seyler  there  was  a  tlecided  fall,  l)Oth 
in  total  solids  and  in  the  proteid-  and  salt-content. 

The  fact  that  the  composition  of  puncture-fluids  does  not 
always  necessarily  vary  during  the  i>rogrcss  of  a  case  has 
been  several  times  demonstrated  in  the  series  studied  in  the 
Leeds  (ieneral  Infirmary.  In  some  cases  there  was  merely  a 
slight  fall  in  the  concentration  of  the  electrolytes.  Thus,  in 
a  case  of  {peritoneal  carcinomatosis  secondary  to  di.sease  of  the 
omentum,  the  only  change  noticed  during  three  weeks  was  a  fall 
in  the  achloride-content  from    03  to    01. 

A  {Mjritoneal  fluiil  due  to  cirrhosis  of  the  liver  showed  a 
fall  in  the  proteid-content  during  five  weeks.  The  achloride 
electrolytes  remaineil  constant,  while  the  chlorides  showed  a 
slight  rise.  The  total  osmotic  concentration  remained  practi- 
cally constant  throughout. 

In  another  class  of  case  the  chloride-content  remained  con- 
stant during  six  weeks,  while  the  achloride  electrolytes  became 
increased.  In  this  case  one  may  set  off  the  change  in  concen- 
tration against  the  fall  in  proteid-content  which  occurred.  The 
fluid  was  associated  with  throml)osis  of  the  jwrtal  vein.  The 
diminution  of  proteid-content  would  naturally  allow  an  increased 
ionisation  of  the  electrolytes  present,  and  there  would  be 
a   diminisheil    inhibitory  effect    on    the   conductivity.      Since, 

•  Zock. 


CMARACTEKS  I'OSSESSEI)  HV  VARIOUS  PUNCTLkK-Kl.UIDS    1  57 

however,  the  diagnosis  of  mcreased  aclUor..!.  ;'l-»;"'vtos  is 
based  on  the  cryoscop.c  result,  .t  beco.nes  evu  ent  '-t  a  a>«  - 
ence  m  albumen  of  14  \^^  "'"t.  woul<l  not  matenalh  alter 
the  values  obtame<l.  Translated  mto  ord.na.v  language  e 
may  say  that  after  a  iM.ritoneal  colle.  tu,n  had  existed  for  mx 
weeks  in  a  case  of  portal  thrombo.s.  the  ch.ef  change  wh.ch 
:^red  was  a  depi,t,on  of  salts  such  as  V^^^^^^^ 
phates.  whUe  the  transudatorv  character  of  the  fluul  becanu 
more  decided,  and  mflammatory  changes  dul  ^-\"'^;^- 

\   case   of    ascites   due    to   disseminated    i)eritoneal    cancer 
(ovani)  was  examined  on  four  occasions  during  as  many  months 
During  all  this  time  the  specific  gravity  and  the  dbuinen-conten 
remained  identical-except  for  a  slight  loss  of  ^^'^----    J^ 
chlorides  steadily  diminished,  though  not   to  a  grea     a m  un t 
(137  to  046  gm.  equiv.).     The  conductivity  diminished  steadily 
as  well,  so  that  the  concentration  of  the  achlondes  in  this  case 

remained  constant.  ,   •   ^      .* 

One  other  case  may  W  referred   to  as  of   sj^cial  in  erest. 

The  patient  was  a  woman  of  middle  age  who  ^^^^^^^^'Z 
ascites  and  an.'emia  for  a  considerable  time.  The  fl  ud  Nas 
Amoved  on  several  occasions,  and  was  at  hrst  I- -Uy  dear 
and  subsequently  opalescent.  Numerous  bacilli  of  the  Baallus 
Zpha,o,on  type  were  met  wUh  in  the  subsequent  apping.^ 
There  wa.  no  fat  present.  The  variations  in  character  of  the  fluu 
we  e  very  slight  and  the  most  remarkable  fact  .;as  the  almost 
Complete  absence  of  coag^dable  proteid  m  h.      The  following 


results 

were  or 

tamec 

1  : 



Sp.  gr. 

e 

E 
s 

0«< 

0 

.ichlor. 

U 

rca. 

a 

1  « 

Colour. 

ti 

c 

J       1 

3 

Aug.  21. 

1008 

025 

"5 

•284 

•065 

' 

0 

Opaksceiit 

Sept.  29. 

lOlO 

0 

121 

•141 

•020 

" 

Nov.     8. 

10095 

Trace 

•132 

170 

•042 

0 

Wliitc 
Golden- yvllow. 

,.        9 

1009 

0  25 

'55 

i 

with      flakes 
of  lymph 

Post  mortem,  the  liver  was  found  to  be  in  an  extreme  state 
of  fatty  degeneration,  the  cells  having  practically  disappeared. 


158 


STL'DIKS    IN    rUNCTUKE-KLUIUS 


i 


V 

I-:. 


hi 

•I    Sj 


The   pancreas  was   iiorinal.     The  kidneys  showed  an  extreme 

cloudy  sweUing  in  tlio  convoluted  tubules,  but  no  increase  in 

the  interstitial  tissue,   nor  any  loucocytic   infiltration.     An  un- 

•ejudired  observer  would  hardly  regard  the  tissue  as  really 

.normal  ;    in  the  absence  of  any  other  abnormality  in  other 

art'    •!    'he  body,  one  must  regard  this  case  as  one  of  toxic 

ne        --  "      The   table  shows  a  progressive  increa.se  in   the 

chloi  -ncentr.ition. 

Th.  ler  case-  which  came  in  for  repeated  tapping  showed 
little  not. worthy  change,  and  they  are  fully  recorded  in 
Section  VI. 

TURBID,    OPALESCENT,   AND    MILKY    EFFUSIONS 
Considerable  tli^-ussion  has  arisen  on  the  nature  of  the  tur- 
bidity which  certaii.  effusions  possess  ;  and  while  in  some  cases 
the  cause  is  not  far  o  seek,  there  are  other  cases  whose  turbidity 
.  even  now  inex        ible.     One  may  <  lassify  the  cases  a.s  follows  : 
A    True  chylon      ^cites  (or  pleurisy  or  pericardium). 
B    P.xMido-chylc  ^  ascites — 
(I)  Hue  i.>  bacteria. 
y>  Due  to  the  presence  nt  gl. 
!j)  Due  to  a  lecitho-globi    >\ 

(4)  Due  to  a  mucin. 

(5)  Due  to  the  physical         , 

(6)  Due  to  other  proteid^     ha 
A.  The  Tkue  Chvlois  i:FFi~    iN- 

plain.  In  this  case  the  tuibidif  ^  du 
of  fat,  and  an  examination  o?  n  uns 
the  case  at  once,  or  the  fact  tl  her 

also  explains  the  class  of  case        ti  wh  cl   or 
An  analysis  l.y  Hopi>e-Seyki   gavi 


Jin. 


(TS  of  the  proteid. 
lobulm 

f  mosT   -imple  to  ex- 

micn  -copic  particles 

will  clear  up 

he  fluid  clear 

to  deal. 


•d  si- 
rei 


1  tibrin,  albumen,  globulin 
Water    <>34-S  I  fat,  lecithin,  cholesterin 


708 
92 


FU4  o  »  int.   it».ini»»',    *-«iv.*-^»^ ---  ^ 

Solids       952  I  latty  acids,  soaps,  and  other  organic  substances     lOS 

Isalts 44 

The  dry  residue  of  an  ethereal  extract  contained  : 

Cholesterin  <  ''3  ,5 

Lecithin 7'5  % 

Olein  and  palmitin         .  .     81I  % 

There  was  no  peptone  or  proteose. 

The  content  of  fat  varies  in  ditlerent  ^pecnnens  from  09  to  07  per 
cent.    .\  case  was  rifently  reported  by  llaminertahr,  in  which  the  patient 


CHARACTERS  POSSESSED  W  VARIOUS  PUNCTURK-FLUIOS    I  59 

•  ^  »  k,ck  in  thf  neck  from  a  horse,  with  a  double  chylothorax  as 
TZt  i^  he  tt "intent  was  h.«her  ,.-.5  P-  cent.)^  I.others.n 
Xtl  twonty-three  cases,  of  wh.ch  eleven  were  clue  to  traun.a.  an.l 
twelve  to  compression  l)y  tumour. 

The  fat  may  be  ideHtified  by  the  use  of  the  microsco,>e,  when 
it  IS  seen  in  the  form  of  minute  granules  Uke  micrococo  wh.ch 
do  not  stain  and  are  soluble  in  potash  and  ether  Sudan  III. 
may  be  used.  Sometimes,  however,  the  fat  ,s  enclosed  m  cell., 
which  may  be  of  very  large  size. 

The  osmotic  concentration  of  chyle  is  slightly  lower  than 

that  of  the  blood,  being  0-291. * 

Contrasting  the  characters  of  chyle  with  those  of  lymph, 
we  find  that  the  former  is  much  richer  in  solids,  three  times  a. 
dch  in  fats,  but  much  lx>orer  m  salts.  The  extractives  are 
high  in  each  case. 

See  also  "  Lacteal  Cysts." 

B   Pseudo-Chylous  Ascites. 

(1)  Due  to  baderia.-Thc  presence  of  enormous  numbers 
of  bacteria  is  occasionally  met  with  even  in  non-septic  effusions. 
The  use  of  a  Chamberland  filter  will  ther  procure  a  clear  filtrate 
Hamburger's  Bacillus  lymphagogon  is  c.casionally  met  with  in 
these  cases,  and  Plate  I.  Fig.  i.  shows  an  example. 

(2)  Due  to  the  presence  of  g/o^H/m.-Micheli  and  Mattirolo 
state  that  the  cause  of    turbidity  in  a  case  which  they  rejxjr 
was    a    molecular    alteration   of    the    globulins    present      The 
molecular  alteration  may  be  really  a  combination  of  globuhn 

"' (3?  a'Sw...  as  one  might  term  it.-Bernert  drew 
attention  to  the  fact  that  globulin  can  combine  with  lecithin  and 
produce  a  turbid  fluid;  but  a  much  more  complete  study  of  a 
cLe  of  this  kind  was  made  by  Joachim  (1903),  who  discovered 
that  it  is  the  pseudo-globnlin  fraction  that  has  an  affinity  for 
ecithin.     After  removal  of  the  pseudo-globuhn  the  fluid  became 
clear,  the  action  of  boiling  m  the  presence  of  acetic  acid  having 
removed  the  source  of  the  turbidity  in  the  hrst  place.     He 
found  0368  part  of   lecithin  pro  miUe.     This  observation  was 
corroborated  by  Gross,   Micheli   and  Mattirolo.   and  Christen. 
The  latter  author,  however,  does  not  think  that  lecithin  is  the 
sole  offender  in  resi^ct  of  causing  a  milky  effusion.     From  one  s 
*  Strauss  and  Grossmann. 


i6o 


STUD! IS   IN    I  TNCTrKE-FLUins 


own  obsiiviition^  tlii>  rxplanation  was  touiul  to  hold  good  in 
a  few  (iiMS.  till'  Miiin.'  ot   turbulity  iR'inf,'  shown  by  its  dis- 


apiH-araiui-  cithfi  on 


boiling  or  on  ^  saturation  with  amnioniiun 


snlphatf. 

(4)  Diif  to  a  niiictn.  -Thi.'  presence  of  excess  of  mucin  in  a 
fluid  may  cause  a  milky  or  opalescent  apiH-arance,  esjx.'cially  if 
the  electrolvte  conditions  do  not  allow  of  its  complete  solution. 

(5)  Dm-  to  the  t^hysual  properties  of  the  proteids.—The  pro- 
gress which  has  been  made  in  colloid  chemistry  enables  us  to 
form  some  conception  of  a  change  that  may  possibly  take  jilace 
in  an  effusion  so  as  to  render  it  turbid.     It  is  sometimes  very 
striking  that   a  first    tapping   brings  out   a  clear,   translucent, 
typically    straw-coloured    fluid,    while    a    subsequent    tapping 
brings   a   perfectly  milky   fluid   to   light.     A  striking  example 
of  this  was  met  with  in  a  case  in  which  the  only  iM>st-inortem 
change  was  extreme  cloudy  swelling  of  the  convoluted  tubules 
of   the  kidneys.     What  change  had   taken   i>lace  between  the 
two  tappings  ^    When,  as  in  the  above  case,  there  is  no  ex- 
planation   forthcoming    that    chyle,    bacteria,    or    lecithin    can 
account  for  the  phenomenon,  may  it  not  Ix?  assumed  that  a 
change  has  taken  place  in  the  physical  projx?rties  of  the  colloids  ? 
If  a  change  in  the  electrical  charge  takes  place  by  which  the 
attraction  l)etween  colloidal  particles  and  ions  is  alteretl,  then 
the  former  may  form  aggregates  of  a  size  suflicieiitly  different 
from  those  in  the  first  tapping  to  make  the  fluid  turbid.     That 
is  to  say,  an  alteration  in  the  electrical  charge  of  the  colloid 
particles  of  the  effusion,  an  alteration  in  the  number  of  particles, 
and  an  alteration  in  the  size  of  the  particles  is  all  that  is  needed 
to  evoke  such  a  striking  macroscopic  change  in  the  fluid  on 
different  occasions.     The  ultramicroscope  would  show  evidence 
of  this  change,  but  apparently  it  has  not,  so  far,  been  impressed 
for  elucidating  this  particular  problem.     Raehlmann,  however, 
in  IQ03,  applied  this  instrument  to  clinical  medicine,  and  in  hi', 
account  of  the  apix-arances  produced  by  various  albuminous 
solutions  he  refers  to  glycogen,  which  in  dilute  solution  has  a 
bluish-white  opalescence.       In  very  dilute   solution  extremely 
minute  particles  of  glycogen,  of  varying  size,  can  be  detected 
throughout  the  solvent,  and  show  a  characteristic  type  of  very 
energetic  vibratile  movements. 

Wc  have,  however,  to  seek  the  cause  of  the  alteration  in 


CHARACTERS  POSSESSED  llY  VARIOUS  I'UNCTURE-KLCIUS    l6l 

electrical  charge,  but  this  is  not  very  diflicult.  (or  it  is  well 
established  that  addition  or  subtraction  of  various  electrolytes 
may  cornplettly  r*"verse  or  nullify  the  electrical  charge  jwssessed 
by  proteid  substances. 

'  In  conne.  tion  with  this  line  of  thought,  the  lu-haviour  of 
globulin  solutions  when  dropjied  into  distilled  water  may  \^ 
referred  to.  As  is  wi-ll  known,  this  clinical  test  for  globulin 
(in  urine,  e.g.)  is  due  to  the  fact  that  in  the  absence  of  electrolytes 
globulin  cannot  remain  in  solution.  The  addition  of  a  few- 
drops  of  a  fluid  rich  in  globulin  to  a  loo-cc.  measure  of  distilled 
water  is  sufficient  to  produce  a  turbitl.  milky  fluid  of  very  similar 
ap|)earance  to  these  pseudo-chylous  effusions.  A  deficiency  of 
salts  and  an  excess  of  globulin  would  thus  suffice  to  produce 
the  effect  of  nature.  The  case  of  toxic  nephritis  referred  to 
might  Ik;  explained  in  this  way,  lx>cause  it  is  a  remarkable 
fact  that  there  was  practically  no  albumen  present,  but  much 
globulin,  and  the  salt-content  was  low.  Of  course  these  factors 
produce  their  effect  by  changes  in  the  electrical  charges  referred 
to.  and  it  is  well  known  that,  after  tapping,  the  globulins  may 
increase  at  the  exi)ense  of  the  albumen.  The  question  is  one 
of  very  great  interest,  and  is  bound  up  with  the  ex[)lanation  of 
the  phenomena  of  salting-out  of  proteids.* 

(6)  Due  to  other  proteids  than  glohiilin.— The  observation  of 
Fuld  and  Levison  that  when  the  vegetable  proteid  edestin  is 
treated  with  <iilute  hydrochloric  acid,  a  strongly  opalescent 
solution  is  obtained,  suggests  that  this  may  throw  some  light 
on  the  causation  of  turbidity  in  some  cases.  Quincke  regards 
the  turbidity  as  sometimes  due  to  an  emulsion  of  albuminous 
granules. 

A  milky  fluid  is  cicscrila-*!  by  I'oijakoft  as  occurring  in  a  case  of  syphilitic 
cirrhosis  of  the  liver  {verifie<i  post  mortem)  associate*!  with  tubal  nephritis. 
The  fluid  contained  1-625  |xt  cent,  proteid  (chiefly  serum  albumen).  1-42 
per  cent.  urea.  6-26  per  cent,  fat  and  extractn es.  He  consid.rs  that  the 
amount  of  fat  is  much  too  small  to  account  tor  the  inilkin(s>.  and  also 
remarks  that  the  fluid  did  not  clear  up  on  shaking  with  ether. 

PERICARDIAL    FLUID 
As  regards  coloui,  specific  gravity,  and  similar  characters, 
pericardial  fluid  falls  in  line  with  pleural  and  i)eritoneal  fluids. 

♦  See  Neisser  and  Friedemann,  ■Stiidien  uber  Ausflockungserscheinun- 
gen,"  Miiiuh.  med.  Woch..  1903,  u  ;  Bechhold.  Zcitsch.  fur  physik.Chemie. 

II 


1 62 


STUDIKS  IN    rUNCTUKK-FLl'IDS 


Thus  in  a  rase  ..f  pnouinonia  intiTcurrcnt  in  the  course  of 
o.inai  caries  •  th.'  i-eri.  ar.lial  ttui.J  was  (ouml  post  niortetn 
tl,  he  a  hrown,  turhi.l  fiui.l.  and  the  iHr..ardmm  showe.t  no 
tra.e  ..(  uiflanmiatorv  -  hani^-e.  The  alhumen  amounted  to  only 
iH  per  rent,  the  ..hlorides  were  very  abundant  (o  I.J7  ^i'"- 
e.n.iv  )  an.l  the  .-..n.hutivity  was  log.j  at  l8^  C.  showmj;  that 
the  a.hloride  ele.  tn.lvtes  amounted  to  ooiq.  and  the  ratio 
a.  hlorides  ;  .hlorides  was  onlv  072.  as  usual  in  transudates. 
Tryptophane  was  present. 

■  Accor.lini,'    to   Hammarsten.    the   chemical   comi)Osition    o» 

jx-ricardial  fluid  is : 


VVatt  r 


...  -/'% 


I  libriii 

globulin 
I  albumen 


OS 
60 

22s 


Solids 


40 


I  proteids  ...  ...  29 

I  Null    ...  7-« 

other  soluble  salts    ...  f4 

insolubli:  salts  ...  04 

fxtrattivts     2'0 

The  proteid-quotient  is  thus  .574.  and  the  proteid-extractivo 

ratio    14- V     The    analyses    K'iven    b\  Friend  and   Halliburton. 

Gorup-Besanez,  Wachsmuth,  Hop|H-Seyler,   and   others,  show 

that  there  is  considerable  variation  in  the  comi)osition  in  different 

sjK'cimens. 

An  analysis  in  a  case  of  tuberculous  pericarditis,  made  by 
Bockelman.  showed  that  this  fluid,  which  was  h;cmorrhagic.  .  on- 
tained  a  considerable  clot,  and  had  a  si>ecific  gravity  of  1024  at 
15^  C.  Its  frcczing-jxtint  depression  wa>  0-51''  C,  indicating  an 
osmotic  concentration  of  o  275  and  a  pressure  of  bi  atmospheres 
(at  o  C .).  The  chlorides  amounted  to  7  gms.  per  litre,  which  means 
a  concentration  of  012,  so  that  the  concentration  of  the  achlorides 
would  amount  to  0155  (expressed  as  NaCl).  The  albumen, 
estimated  by  Esbach's  instrument,  was  41  i^r  cent.,  and  the 
total  nitrogen  was  0"2b8  gms.  ix;r  cent. 

A  case  of  chylo-iwricardium,  recorded  by  Hasebrock,  con- 
tained lo-  ^6  ,)er  cent,  solids,  73  per  cent,  albumen,  107  ix^r  cent, 
fat,  033  ix?r  cent,  of  cholesterin,  0177  per  cent,  lecithm,  and 
0()3  per  cent,  of  salts. 

Concctiration  of  Hydrogen  /oH.s.-The  normal  fluid  gives  for 

log  C„- 7-4400,  meaning  an  alkalinity  of  ^  ^^.jj   potash. 

•  Reg.  No.  8072. 


CHARACTERS  POSSESSED  BY  VARIOUS  PUNXTURE-KLl'IDS    163 

SYNOVIAL   FLUID 

Tlu  .  hief  jwruliarity  of  this  fluid  is  the  sp^rial  variety  of 
mucin  which  it  contains.  This  mucin  does  not  reduce  FehHnR. 
and  behaves  hke  a  nucleo-albumen  or  nudeo-proteid.  It  has 
been  analysed  by  von  Hoist,  and  by  Salkowski,  who  called  it 
synovin.  Synovial  fluid  is  alkalin.-.  of  yellowish  colour,  and 
may  be  turbid  even  in  health.  The  following  analyses  form 
:\  useful  comparison : 


Normal 
(tUmmar(Un). 


SynovilU 
(lloppc-Seylei) 


Water 

Mucin    ... 

Proteid  

Extractives  and  fat 

Salts      

Sodium  chloride 


948* 

2 

39 
5 

3 
6 


938 

7 

5« 

4 
9 


Uric  acid  may  occur  in  synovial  fluid,  especially  in  gouty 

effusions. 

Antiferments.— Suppuration  joint  fluid  was  found  by  Miiller 

to  contain  no  antiferment. 

As  regards  the  clinical  value  o«  examination  of  synovial 
fluid,  one  must  admit  that  the  inti  rest  here  lies  mainly  in  the 
bacteriological  characters,  and  iierhajis  no  less  imi^rtant  are 
the  cytological  characters. 


HYDROCELE    FLUID 

The  colour  varies  from  straw-colour  to  a  dark  brown  or 
greenish  colour.  The  siJecific  gravity  of  hydrocele  fluid  varies 
between  loib  and  1026.  An  analysis  given  by  Hammarsten 
gave  938  jier  mille  water  and  61  per  mille  solids,  which  con- 
sisted of  fibrin  (0-50),  globulin  (13-25),  albumen  (35-94).  ether 
extractives  (402),  salts  (926),  sodium  chloride  (619). 

Lecithin,  and  traces  of  reducing  substance  and  of  urea  are 

found. 

Metalbumen  \  and  paralbumen  have  been  found  in  hydrocele 

•  For  convenk-nce,  the  nearest  whole  number  is  given. 
I  Devillartl. 


MICROCOPY    RESOLUTION    TEST   CHART 

I  ANSI  and  ISO  TEST  C  'ART  No   2i 


1.0 


I.I 


;-  Ilia 

I:  1^ 


12.5 
2.2 
ZO 

1.8 


1.25 


1.4 


1.6 


^  ^^PLIED  irvMGE     Inc 

S^S  '^j^-iesler,    New    '  iri.  !46C9        USA 

'"SS  ;7^6>    ^er    -    03OO  -  Phone 

==  (716)   2B8  -  5989  -  Fox 


1 64 


STUDIES  IN   PUNCTURE-FLUIDS 


fluids.  Old-standing  cases,  as  with  all  cysts,  may  present 
abundance  of  cholestcrin.  The  jiossihility  of  finding  filaria  in 
hydrocele  fluid  may  be  just  mentioned.* 

Succinic  acid  is  said  to  be  present  in  some  e.xamples  f  and 
occasionally   inosite. 

Ferments  and  Antiferments. — In  syphilitic  cases  the 
hydrocele  fluid  may  give  a  jMsitive  reaction  with  the  serum 
lest  (Wassermann's). 

Aqueous  Humour.— Lohnicyer  «ives  tlu-  lollowins  analysis  :  Water 
968-87  per  mille,  solids  lyii  per  mille,  consisting  of  proteids  (serum- 
albumon,  and  Rlohulin  I'lz).  extractives  o-^i,  NaCl  f.-8.».  other  salts  081. 
There  were  no  cellular  elements  present.  The  specific  gravity  varies 
between  1003  and    i<>o<>. 

GriinhaRcn  found  a  reducing  substance  in  it,  which  was  not  sugar  ; 
he  also  found  urea  and  sarcolactic  acid  ("  paralaclic  acid  "). 

The  absolute  <((i(//n.  determined  by  C.  Foain  the  case  of  a  horse,  gave  : 


•1328 


log.  C.I 
—  -•049 


^11  X  10  -  8 

8 '93 


vhich  shows  it  to  be  practically  ionically  neutral. 


AMNIOTIC    FLUID 


Amniotic  fluid  has  been  studied  very  closely  in  order  to 
decide  whether  it  is  to  be  regarded  as  a  transudate  or  as  a 
urinary  fluid.  +  The  specific  gravity  is  usually  low  (1008)  and 
the  solids  only  amount  to  about  11  per  cent. 


•  Salm. 

t   Hammarsten. 

+  Hamburger  studied  the  amniotic  and  allantoic  fluids  in  order  to 
deci*de  this  (luestion  bv  determining  the  freezing-point  depression,  in 
association  with  his  blood-corpuscle  method  (which  informs  about  those 
substances  for  which  the  red  cells  are  not  permeable).  He  found  the 
freezing-point  of  the  two  fluids  identical,  while  the  allantoic  fluid  requires 
less  dilution  than  amniotic  fluid  in  order  to  cause  h;rmolysis  ;  the  allantoic 
fluid  therefore  contains  bodies  which  do  -lOt  exert  any  osmotic  pressure 
on  the  red  cells  (urea).  This  means  that  allantoic  fluid  is  a  kind  of  foetal 
urine.  Jacque  had  an  additional  argument  for  his  belief,  namely,  that 
the  ratio  between  NaCl  and  soluble  salts  vanes  greatly,  whereas  if  the 
allantoic  fluid  were  a  transudate  the  ratio  would  be  constant  and  the 
same  as  the  blowl.  The  same  arguments  hold  for  amniotic  fluid,  though 
the  evidence  is  less  convincing  in  this  case. 


CHARACTERS  POSSESSED  BY  VARIOUS  PUNCTURE-FLUIDS    16$ 


The  substances  which  have  Ijeen  found  in  hydramnios  fluid  • 


are  : 

Nitrogen-content  t  ■.. 

Globulin 

Albumen 

.Sugar  {not  levulosc)  J 

A  mucin  § 


o-2737o 
1272 


L'rca 

L'ric  Acid    ... 

Allantoin    ... 

Ash 

1 01,  CO,,  p.Oj,  so, 

<  Na.O,  k ,0,  CaO,  MgO,  Fc 


oim7„ 

00635^ 

present 

7-8367» 


Osmotic  Concentration. — The  normal  freezing-point  de- 
pression is  0510'  i!  or  o-475-,t  which  corresponds  to  an  osmotic 
concentration  of  0-275  or  0256,  or  a  pressure  of  61  or  5-6 
atmospheres  at  o^  C.  In  cases  of  hydramnios*  it  is  less,  being 
found  to  be  0395°  C,  and  in  cases  of  eclampsia  it  is  increased  i| 
(o-6Kr  C). 

Hamburger  finds  it  isotonic  with  the  blood-serum. 

In  cases  of  ectopic  gestation  Zangemeister  found  the  osmotic 
concentration  0-301,  and  that  the  longer  the  time  that  has 
elapsed  since  the  death  of  the  foetus,  the  more  concentrated 
does  the  fluid  become,  owing  to  the  salts  passing  out  from  the 
intestine  into  the  sac. 

The  electro-conductivity  in  a  case  observed  by  me  was  1070 
at  18°  C,  and  the  chloride-content  0-507  per  cent.,  so  that  the 
achloride  electrolytes  amounted  to  0030,  the  ratio  of  achlorides 
to  chlorides  being  therefore  035. 

CoNCENTR.\TiON  OF  HvDROGEN  loNS. — Fo4  obtained  the 
following  values  : 

IT  log.  C„  Ch.x.o"* 

•1362  —  7-1072  7-813 

Scipiades  and  Farkas  found  for  Ch  x  io""  g.o. 

The  fluid  is  practically  ionically  neutral. 

Ferments. — Bonoli  examined  the  ferment-content  in  am- 
niotic fluid  and  found  that  trypsin,  chymosin,  autolytic- ferment 
and  glycolytic-ferment  are  never  present,  while  diastase,  pepsin, 
fibrin- ferment  and  lipolytic-ferment  are  always  present.  A 
ferment  which  can  split  up  salol  is  also  always  present.  He  found 
a  catalytic  action. 

Antiferments. — Bab  failed  to  find  antibodies  to  syphilis  in 
an  amniotic  fluid  in  a  case  of  congenital  syphilis. 

•  Stozyzowski.  t  Scipiades  and  Farkas. 

I  Griibe  and  Griinbaum.  §  Schere  and  Weyl. 

ii  VicarcUi  and  Cappone. 


i66 


STUDIES   IN    PUNCTURE-FLUIDS 


i 


CEREBROSPINAL   FLUID 

The  utility  of  a  study  of  this  fluid  has  come  to  be  widely 
recognised,  so  that  lumbar-puncture  *  is  a  frequent  occurrence, 
and  regarded  as  of  very  great  value.  While  much  stress  has 
been  hitherto  laid  on  the  cellular  characteristics,  it  may  be 
safely  said  that  it  is  chemistry  which  will  afford  us  full 
realisation  of  the  diagnostic  information  which  lumbar-puncture 
can  supply.  In  recent  literature  tests  have  been  given  which 
are  simple  to  perform,  and  promise  well  for  clinical  diagnosis. 

It  has  boon  asserted  tliat  even  if  the  cerebrospinal  fluid  served  no 
iliaRnostic  purpose  it  wouhl  still  be  ol  use  to  perform  lumbar-puncture  as 
a  therapeutic  measure.  v.  Bokay  has  shown  that  a  therapeutic  ettect 
can  be  expected,  owing  to  the  relief  of  pressure  in  the  cerebrospinal  canal, 
and  to  tht  removal  of  bacteria  or  their  toxins,  so  that  lumbar-puncture 
should  be  performed  two  or  three  times  in  a  bad  case.  The  pressure  of 
the  fluid  may  be  measured  as  it  comes  out  of  the  cannula.  It  may  be  found 
to  vary  in  amount  almost  from  hour  to  hour. 

Cerebrospinal  fluid  is  always  slightly  alkaline,  and  has  a 
iow  specific  gravity  (1003-8),  which  disease  does  not  appreciably 
alter,  except  in  the  case  of  meningitis,  where  the  specific  gravity 

is  increased,  t 

Naked-eye  Characters. — Colour. — Normally  the  fluid  should 
be  perfectly  dear,  aUhough,  according  to  Pilcz,  it  is  not  invariably 
turbid  in  disease,  since  in  a  case  of  subacute  tuberculous  lepto- 
meningitis it  was  clear.  As  a  rule,  however,  a  clear  fluid  in- 
dicates that  there  is  no  suppurative  meningitis. 

♦  Ltnnbar-pnnclme. — The  requisites  are:  (i)  A  trocar  three  to  four 
inciies  long,  of  the  diameter  of  an  antitoxin  syringe-needle.  (2)  Means  for 
sterilising.  (3)  Sterile  test-tubes.  (4)  Culture  media.  The  puncture  is 
made  a  third  of  an  inch  to  right  of  mi<ldle  line  between  third  and  fourth 
lumbar  vertebra;  (=  a  line  drawn  between  the  upper  points  of  the  iliac 
crests).  The  patient  should  lie  on  his  left  side,  with  his  knees  drawn  up. 
After  the  usual  aseptic  procedure  (no  chemicals  must  be  used)  the  trocar 
is  taken  up  and  entered  (at  the  point  marked  with  the  left  forefinger), 
forwards,  slightly  upwards  and  slightly  inwards,  using  steady  uniform 
pressure.  It  may  be  necessary  to  withdraw  the  needle,  owing  to 
intervening  bone.  The  needle  having  been  correctly  introduced,  the 
fluid  will  run  out,  and  is  allowed  to  run  into  the  sterile  test-tube,  the 
first  (hops  being  rejected.  It  may  be  allowed  to  run  straight  into  the 
culture-tubes  also  (human  blood  serum,  agar,  glycerine-agar). 

t  Sahli. 


CMARACTKKS  POSSESSED  BY  VARIOUS  PUNCTURE-FLUIDS    167 

A  yellow  colour  has  been  met  with  in  tuberculous  meningitis 
where  red  cells  were  not  abundant,*  and  in  a  case  of  cerebral 
haemorrhage  which  had  j)erforated  into  the  meningeal  cavity.t 

A  red  colour  has  been  met  with  in  a  case  of  subarachnoitl 
h;emorrhage.     If  the  blood  is  accidentally  present  the  colour  is 

paler.  I 

Turbidity  is  generally  due  to  a  great  increase  of  pus-cells. 

The  following  table  shows  some  of  the  characters  pjossessed 
by  the  cerebrospinal  fluid  in  cases  of  epidemic  cerebrospinal 
meningitis,  as  observed  by  H.  v.  Bennecke : 


0  u  1 

Naked^ye  Character!. 

Albumen. 

Neutro- 
philes. 

.-0  = 

Lympho- 
cytes. 

.11 

I 

Very     turbid ;     flakes     and 

'  -,- 

! 

threads  on  standing 

99% 

Trace 

C 

!   + 

2 

Very  turbid;  flakes 

68 

2 

30 

Jr 

3 

Turbid;  flakes        

Moderate 

99 

Trare 

0 

... 

4 

Slightly  yellow ;  only  a  sus- 

picion of  flakes 

J%jEsbach) 

8 

8 

84 

+ 

s 

Fairly  turbid            

99 

Trace 

0 

6 

Turbid;   flakes        

1 

80 

1  race 

21 

7 

Slightly  turbid;  a  few  flakes 

1 

90  95 

05 

J-4S 

1     + 

Percentage  Composition. — From  some  analyses  by  Halli- 
burton we  iearn  that  cerebrospinal  fluid  contains  about  990  jier 
cent,  of  water  and  i  per  cent,  of  solids,  of  which  08  {ler  cent,  is 
formed  of  extractives  and  salts,  the  remaining  02  per  cent, 
consisting  of  proteid  matter. 

Proteid  Constituents. — Much  dispute  has  arisen  as  to 
whether  albumen  is  present  or  no,  but  it  may  be  assumed,  from 
the  investigations  of  Quincke,  Riecken.  Gumprecht,  Lenhartz, 
Nawratzki,  Babesch,  and  others,  that  cerebrospinal  fluid  normally 
contains  02  to  i  jier  mille  of  albumen,  while  the  amount  rises 
higher  than  this  in  meningitis,  in  tumour  cerebri,  in  apoplexy, 
and  in  paralytics  (Esbach's  method). 

Frenkel-Heiden  examin  d  the  cerebrospinal  fluid  from  various 
cases  of  nervous  disease,  especially  as  regards  the  amount  of 
albumen  and  the  total  nitrogen-content.  The  albumen  was 
precipitated  by  adding  10  to  15  times  the  bulk  of  absolute  alcohol, 


♦  Nissl. 


t  Sicard. 


Siemerling. 


1 68 


STUnilS   IN    I'UNCTUUK-FLUIDS 


j 


1,1 


I 


■i 

h  ■ 


and  allowed   to  stand   24  hours.     The   following   results  were 
obtained  :  * 

Al.HUMKN-LoNTENT   OK   Cf.FEBROSIMNAL    FlUID   (FrENKEL-HeIDEN) 


Below  1% 


lto»% 


3  to  3-S% 


Above  a  8  % 


Dementia  Paralytica 
Tuberculous  Menin- 
gitis 
Pontine  Tumour 
Amaurotic  Idiocy 
Normal  f 


Tuberculous     Men- 
ingitis (2  cases) i 
Tubercle    of    Brain 

(3  cases) 
Glioma  Cerebri 
Serous  Meningitis 
Pachymeningitis 

Hscmorrhagica 
Acute  Amentia 


Tabes  Dorsalis 
Tuberculous     Men- 
ingitis (2  cases)  ^ 
Tubercle  of  Brain 


Dementia 
Paralytica 

Above  3%^  in- 
dicates        a 
definite     in- 
flammatory 
condition  X 


The  maximum  values  are  found  in  a  case  of  general  jiaralysis 
of  the  insane  and  in  one  of  tuberculous  meningitis,  but  no  con- 
stant-values for  particular  classes  of  fluid  were  obtained.  He 
lays  the  chief  stress  on  the  variations  in  residual  nitrogen,  which 
was  always  conspicuous  in  amount,  and  a  comparison  of  the 
distribution  of  the  nitrogen  over  the  albumen  or  the  urea  showed 
that  in  a  case  of  jxjsitive  tumour  there  was  sixteen  times  as  much 
nitrogen  attached  to  the  urea  as  there  was  to  the  albumen,  while 
in  other  cases  the  reverse  condition  was  noted. 

The  following  ratios  are  obtained  §  from  the  analyses  made 
by  this  author  : 


Disease. 


Total  Nitrogen        Total^Nitroeen         Urea-nitrogen 
TUbunierrnUrogcn.;     Urea-nitrogen.       Albumen  nitrogen. 


1-8 

256 

07 

.V04 

1-23 

2S2 

I  02 

1-2 

085 

i6-5 

I  62 

160 

Tubercular  Meningitis    ... 
Simple  Meniniiitis  ji 
General  P.iralysis 
Pontine  Tumour  ii 

The  precise  indications  as  to  particular  diseases  from  the  albumen- 
content  such  as  are  given  by  Rieken  are  too  artificial. 

•  The  classification  is  my  own. 

t  Quincke. 

+  Fiirbinger  says  that  more  than  i  per  millc  of  albumen  means  tuber- 
culous meningitis. 

§  1  do  not  reproduce  the  actual  figures,  as  the  ratios— which  the 
author  of  the  paper  does  not  work  out     seem  more  interesting  and  striking. 

l!  The  value  for  total  nitrogen  in  these  cases  is  less  than  that  for 
albumen-nitrogen  +  urea-nitrogen.     Surely  an  error. 


CHARACTERS  POSSESSED  HY  VARIOUS  VUNCTURE-KI  UIDS    l6<> 

Globulin  is  always  present,  antl  the  amount  of  it  which  is 
present  has  been  utiUscd  by  Nonnc  and  Ajielt  for  diagnostic 
purix)ses.  They  employ  ammonium  sulphate  as  a  precipitant, 
using  the  abundance  of  the  precipitate  as  a  measure  for  the 
amount  of  globulin.  The  fluid  is  mixed  with  an  equal  quantity 
of  saturated  ammonium  sulphate.  If  a  turbidity  apjiears  in 
three  minutes,  the  reaction  is  positive.     (Phase  I.  reaction.) 

Thf.  Globulin-reaction  in  Cfrfbrospinal  Filid* 


Nonne'i  Cases. 


|%ofCa»ef| 

No.  of    I  in  which 

Cases  Ki-   Lymt-ho- 

amined.    cy'teswere 

Present. 


Literature. 


No.  of 
Cases. 


%ofCas« 
in  which 
l.ympho- 

cytesweie 
Present 


Disease. 


No.  of 
Cases. 


Caaca 

'  where 
Phase  I 
Reaction 

was 
Positive. 


76 
36 

r 
1/ 

2 

35 
«9 
•3 

13 

>4 

5 

30 

5 


97 
9S 
75 
40 
100 

33 

4 

15 

33 

23 

40 
o 
o 


33  < 
95 
14 
76 
>S 
18 

«7 

3! 
«5 

«5 
«4 

37 
6 


98 

05 

80 

40 

100 

44 
6 

>5 

23 
24 

65 
o 


Dementia  Paralytica 

22 

100 

Tabes  Dorsal  is 

17 

93 

Lues  III. 

«5 

92 

Lues  II. 

S 

20 

Lues  Congenita 

2 

100 

Healed  Lues 

18 

0 

Alcoholism 

12 

0 

Idiopathic  Epilepsy 

10 

0 

Apoplexia  Sanguines 

... 

Sclerosis  Multiplex 

Tumor  Cerebri 

3 

33 

Neurasthenia,  Hysteria 

12 

0 

Health 

12 

0 

It  is  convenient  to  add  acetic  acid  to  the  filtrate  resulting 
from  ammonium  sulphate  ;  boiling  will  bring  down  the  albumen, 
and  it  may  be  estimated  by  weighing.f 

Siemerling  uses  magnesium  sulphate  as  an  indicator  of  the 
character  of  cerebrospinal  fluid.  If  a  saturated  solution  of 
magnesium  sulphate  be  added  to  normal  cerebrospinal  fluid, 
and  the  mixture  filtered  and  boiled,  the  filtrate  will  remain  clear 
in  normal  cases,  while  if  from  a  case  of  dementia  paralytica, 
it  will  become  turbid.  The  addition  of  acetic  acid  causes  a 
precipitate  of  serum-globulin. 

Protalbumose.— Deutero-albumosc  has  been  occasionally 
met  with  by  Halliburton  and  by  Donath. 

Variations  in  Composition  on  Successive  ra/'/)tHg.— Halliburton 

*  From  Mlinch.  fned.  Wocli.,  1907,  p.  42. 
t  Nissl. 


r  t| 
f  I 


STUniKS  IN   rUNCTURE-KLUlDS 


W 


lound  thf  spt'citic  gravity  to  rise  and  the  amount  of  protcid  to 
rise  from  045  per  cent,  to  ofx)  per  cent,  and  072  per  cent,  in  a 
case  of  chronic  hydrorephaUis  which  was  tapped  at  mtervals.  He 
found  the  reducing  substance  (see  fx'low)  also  to  increase  in 
amount  under  these  circumstances,  being  only  present  in  trace 
to  begin  with. 

(iiMi'osiTioN   UK  Ckhkhkiisi'INAi    Fluid  in   IIyhkocki-hai.l's 


Dry  bubslance. 


Ath. 


Albumen. 


Author. 


Kemarki. 


II' 


09* 
109 

0-97 


0S4 
07S 
078 


0'12 
.,■31 
OlS 


(Jrc^bcr 

•» 

Neumtistir 


.Mian  of  17  specimens 


Nitdeo-albmnen  is  found  only  in  tubercular  meningitis,* 
and  it  is  convenient  to  precipitate  it  when  searching  for  tubercle 
bacilli,  as  they  will  become  entangled  in  the  precipitate. 

Reducing  5/</j.s7(i«cf.— Halliburton  extracted  this  substance 
by  using  alcohol  as  a  precipitant.  The  residue  is  dissolved  in 
water  and  extracted  by  the  use  of  neutral  lead  acetate,  when, 
after  removal  of  the  lead  by  H..,S,  the  filtrate  can  be  shaken 
with  ether.  He  considers  the  substance  to  be  pyrocatechin, 
since  it  does  not  give  a  comix)und  with  phenylhydrazin.  Iron 
perchloride  gives  a  green  colour,  and  potash  gives  a  brown 
colour. 

Lannois  and  Boulard  state  that  glucose  is  present  to  the 
extent  of  04  to  05  per  cent,  in  normal  cerebrospinal  fluid,  and 
that  it  may  disap}>ear  from  the  fluid  when  meningitis  develops. 

Galactose  was  found  in  hydrocephalus  fluid  by  Langstein. 

Lactic  Acid  has  been  found  to  l>e  always  present  in  cerebro- 
spinal fluid  by  Lehndorff  and  Baumgarten,  though  it  is  specially 
abundant  in  cases  of  meningeal  inflammation. 

Carbaminic  acid  was  found  in  a  case  of  eclampsia. t 

Bile-pigments  and  bile-acids  have  been  found  in  cases  of 
jaundice.  I 

Cholin. — The  discovery  of  cholin  in  cerebrospinal  fluid  by 
Halliburton  and  Mott  in  cases  of  organic  nervous  disease,  as 
opposed  to  functional  disease,  is  the  most  important  advance 
in  our  knowledge  of  the  chemistry  of  cerebrospinal  fluid.     The 

•  Sahli.  t  ^<-  B-  Kofmann. 

*  Gilbert  and  Castaigne. 


CHARACTERS  POSSESSED  BY  VARIOUS  I'l'NCTURE-KLUIDS    17I 

cholin  is  derived  from  the  breaking  down  of  nervous  tissue  (see 
Section  I.  under  Lecithin). 

In  order  to  detect  it,  the  fluid  is  treated  with  absoUite  alcohol, 
and  the  extract  evajwrated  to  dryness.     Alcohol  is  again  added, 
and  the  process  rejx'ated  several  times,  the  last  alcoholic  solution 
l)eing  treated  with  an  alcoholic  solution  of  platinum  tetrachloride, 
when  a  yellow  precipitate  results.     This  is  washed  with  alcohol 
and  dissolved  in  15  i)er  cent,  alcohol.     On  concentration  yellow 
crystals  of  the  double  chloride  of  cholin  and  plati.nun  separate 
out.     To  distinguish  these  microscopic  crystals  from  a  similar 
l)otassium  double  salt,  a  strong  solution  of  iodine  in  jwtassium 
iodide   is   added,   when   dark   brown   dichroic   plates  of  cholin 
iwriodide  (C.-.HhNOI  .  18)  result,  while  the  i>-         jm  salt  does 
noi  alter.     On  standing,  the  cholin  i)eriodid<     .eaks  up  into  oil- 
globules.     A  simpler  method  of  difterentiat.un  is  to  look  at  the 
crystals  with  the    jwlarising  microscope,  when    the  cholin  salt 
comes  out   bright   and    the    jwtassium    salt   becomes   invisible 
(Rosenheim's  recent  method  of  identifying  cholin  by  the   use 
of  alloxan  is  apparently  not  reliable). 

The  presence  of  excess  of  potassium  salts  in  cerebrospinal 
fluid  is,  however,  regarded  by  Halliburton  and  Mott  as  in  itself 
evidence  of  nervous-tissue  destruction. 

other  Tests.— (i)  Make  a  saline  solution  of  the  alcoholic  extract  anil 
inject  it  into  an  animal.  H  cholin  be  present,  the  arterial  pressure  will 
fall,  a  phenomenon  which  will  be  prevented  by  a  preliminary  dose  of 
atropine. 

(2)  Dissolve  in  alcohol  and  treat  with  concentrated  alcoholic  picro- 
lonic  acid.     A  precipitate  of  cholin  picrolonatc  is  produced.* 

Ferments.— A  diastatic  ferment  has  been  descril)ed  by 
Cavazzani  and  Grober  as  present  in  the  iiuid  of  chronic  hydro- 
cephalus. 

And  ferments  have  been  found  in  tuberculous  meningitis  by 
Muller,  while  they  are  absent  in  cerebrospinal  fever.  In 
syphilitic  nervous  disease  Weygandt  found  that  antilx)dies  are 
present — that  is  to  say,  certain  albuminous  substances  in  the 
normal  spleen  interfere  with  haemolysis,  especially  when  the 
cerebrospinal  fluid  of  a  tabetic  is  added.  According  to  Meru 
and  Levaditi,  73  per  cent,  of  cases  of  general  paraK-sis  of  the 

»  Otori. 


172 


STUMKS  IN    rUN(  TURE-FLUIDS 


I! 


insane  contain  thcso   antilxxlies,  and  W)  jwr  cent,  of  cases  of 
tabt's  contain  ttu'ni. 

Is()i<(..\M<  Cons  I  rnKNTS.  -Sodium  chloride,  sodium  car- 
bonate, sodium  phosphate,  and  earthy  phosphates  are  met  with. 
The  iK)tassium  salts  are  increased  in  amount  in  organic  nervous 
(Usease  a(  cording  to  HaUiburton.  The  ratio  between  Na  and  K 
has  been  made  out  by  various  authors  to  be  1:2-43  (C.  Schmidt), 
I  :  2i(>  (Yorn).  i  :  21-5  (F.  Miiller),  i  :  Jji  (HaUiburton).  It 
must  be  remembered  that  this  excess  of  |)otassium  salts  which 
has  l)een  dcsi  ribed  is  only  relative  ;  the  sodium  salts  are  abso- 
lutely in  excess  in  all  cases. 

I'HVSICO-CHEMICAL   CHARACTERS  OF    CEREBROSPINAL    FlUID. 

The  Osmotic  Concentration.— Oh^eTva.Uom  by  Fuchs  and 
Rosenthal  in  different  diseases  have  given  the  following  results  : 


Diseaie. 


Freeiinf-point  ;         Oimotic 
Depression.       Concentration.* 


Pressure  in 
Atmospberes.' 


Tubercular  Meningitis     ... 

Dementia  I'aralytica        

Chronic  Alcoholism 
Epilepsy     ... 
Various  Cases 

3898  t  Tubercular  Meningitis    .. 

3899  t  Old  Cerebellar  Abscess  .. 


046 
054 
054 
052 
053 


0337 
0524 


■248 
'291 
•291 
■281 
■286 

■181 
■283 


6-5 
6-5 
6-2 

6-3 


40 
6-3 


The  Electrolytes.— Observations  of  cases  in  the  Leeds  General 
Infirmary  have  given  the  results  shown  in  the  table  on  next  page. 

These  results  show  that  the  achloride  electrolytes  are  always 
very  scanty,  whether  the  meninges  be  affected  or  no.  The  amount 
of  chlorides  is  usually  high  and  the  total  concentration  of  electro- 
lytes is  also  considerable.  The  last  column  shows  a  very  great 
uniformity  in  the  different  cases. 

The  electroconductivity  varies  with  the  freezing-point 
depression,  except  in  cases  of  meningitis. 

Ionic  Acidity.— Fok  records  the  following  values  in  a  case  of 
norma!  cerebrospinal  fluid : 

TT  log.  Cii  Cm  X  .r* 

•1428  72234  597  or  6-35 

Titration  against  tornasole  gave  an  alkalinity  of       KOH. 


I   have  added   these   values. 


■f  Own  observations. 


CIIARACTKKS  POSSESSKD  UY  VARIOUS  PUNCTURE-FLUIDS    173 


Viscosity— Too  few  detoi- 
minations  have  Ix-en  made  to 
allow  any  ilecUutions  to  In- 
made.*  In  a  case  in  thi-< 
hospital  the  viscosity  was 
found  to  Iw  1-^2,  taking  water 
as  I. 

CYSTIC   FLUIDS 

Ovarian   Cysts.— At    the 

present   day   the    comiwsition 
of  ovarian  cysts  is  a  subject  ot 
comparatively    little     import- 
ance.     From    the    theoretical 
standpoint,      however,      their 
colloidal  contents  possess  very 
great  interest.      It  does  some- 
times    happen,     nevertheless, 
that  a  fluid  supjjosed  to  be  a 
peritoneal    effusion    is    really 
derived  from  an  ovarian  cyst, 
so  that  the  chemical  and  other 
characteristics    of    this    class 
of  fluid  demand  consideration. 
Among    cystic     fluids,    many 
varieties  of  which  call  for  study, 
the  ovarian  cysts  are  the  mo>t 
frequent  and  jxjssess  the  most 
decided  characters. 

The  numerous  varieties  of 
ovarian  cysts  which  have  lieen 
described  by  gynaecologists 
frequently  show  }>erfectly  dis- 
tinct varieties  of  contents.  The 
unilocular  cysts,  as  a  rule, 
contain  perfectly  clear  and 
watery  fluid,  while  the  multi- 
locular    cj^ts     may    contain 

•  Fuchs  and  Rosenthal. 


.a  I 


s  a  2 1.  ^  , 


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•74 


STUDIES  IN   rUNCTURE-FLUIDS 


different  (onns  of  »xtr»iiuly  imicmoiis  material  in  the  tlifferent 
loruli  ;  thus,  in  one  cavity  there  may  Ih>  a  jelly-like  mxss, 
another  may  contain  a  mucilaginous  clear  fluid  which  will 
just  iK)ur,  another  may  contain  a  bright  green  solid  jelly, 
and  so  on.  This  is  a  rather  remarkable  fact,  and  a  section 
throuRh  a  cyst  of  this  kind  consequently  furnishes  a  very  striking 
ai)iM-arance.  The  explanation  of  such  features  may  Ik-  found  in 
tlu'  character  of  the  lining  cells,  for  in  some  cases  there  is  an 
abundance  of  goblet-cells  in  the  epithelium,  while  in  others 
theie  is  relatively  little.  In  other  ca.ses,  again,  the  epithelium 
is  iK-rfectly  intact  and  stains  Ix-autifuUy  in  the  histological 
preparation  (Fig.  lo),  while  in  other  cases  the  epithelium  is 
practically  universally  dead,  the  only  indication  of  the  structure 
of  the  original  cyst  bemg  the  connective-tissue  strands  which 
separate  the  locules. 

It  seems  so  remarkable  that  there  should  lie  these  alisolute 
differences  in  the  physical  characters  of  the  fluid  in  different 
loculi  of  tlu-  same  cyst  that  the  question  nmst  be  worth  dis- 
cussing.    In  order  to  arrive  at  any  opinion,  we  shall  have  to 
discuss  certain  projKTties  of  colloids,  and  discuss  also  the  histo- 
logical apiwarances  in  the  cysts.     In  the  first  place,  the  problem 
may  be  merely  one  of  a  conversion  of  a  sol  into  a  gel  (in  this 
instance,   of  course,    a   hydrosol   into  a   hydrogel),   but   if  we 
endeavour  to  ascertain  what  explanation  there  is  to  be  had  for 
the  change  from  sol  to  gel  in  general  we  find  that  there  are  abun- 
dant  theories,  but  that  very  little  is  really  dcnnitely  under- 
stood.    Perhaps  the  simplest  explanatrn   is  one  which  takes 
into  account  the  surface  tension.     We  have  already  mentioned, 
when    discussing   the    difficulties    of    removing   albumen    com- 
pletely, that  when  mastic  is  gradually  added  to  an  albuminous 
solution,  tl\e  particles  of  mastic  lx>come  distributed  over  the 
particles   of    albumen    (hydrosol)   without    any   visible   change 
occurring  until  a  certain  point  has  been  reached,  when  the  amount 
of  mastic  causes  the  separation  of   the   proteid,   the  particles 
of  the  latter  having  become  exceeded  in  numl)er  by  the  former, 
so  that  no  more  distribution  of  mastic  can  take  place.     The 
same  may  hold  in  the  colloid  of  ovarian  cysts.     The  addition 
of  electrolytes,   for  instance,  from   the  circulating  blood  may 
result  in  the  conversion  of  the  hydrosol  into  the  hydrogel,  the 
process  being  one  of  modification  of  the  electrical  charges  origin- 


e 


V 


yf^Wf 


Fir,,  lo.  -From  a  Cysto  Adiiioina  Papillifoniin  Ovarii, 
I'l-liowaclivi-ly  ■'eiriiinuKol.l<l-r(ll«  ;  tlu'siirilinn  lurricKiiiiiilir-iiinuiiiliiu  im-i->iir>-. 
II.  (I.  qiilluli.il  KvXU  ;  /■,  -ii]>ii<.rliiiK  ti-<iu' ..(  IIk  lil.iimiitoii«  pnm— «  ;  f,  c.i|iill;iry  • 
</,  iiiit.ill.  liuiirc  ill  ,1  ^l.l.l^•t•lt■ll.  ii.irtly  Ih-iumHi  Itu-  i>l.iiii  nf  tin-  -.itimi  ;  lii'<  ill  the 
lavily  lif  llu-  iy<t.  only  llii-  l>a-iil  i«>rli..ii»  i.f  llu-  i.lK  ,A  .»'  iin-  !.•  \<c  *i'-ii  /.li-* 
il<ilii<ik;<*ll  lllllll  ,  I  >c.    4. 


Fici.  II.  — Fioin  a  Miiltilocul.ir  Ovarian  Cyst. 
The  ilrawini!  shuw^  the  will  limiliii«  hKiilu*  tt  (rum  lm.uhi-i  '),  ami  mii  e-ach  <ilt 
there  i*  an  ejiilhelial  oiveriiiK.  d  ami  .•      The  furmer  i-i  i.i)nii»>vvl  111  aiiilv  nf  i-c.tilel 
telU  in  a  -liiiKle  rnw,  aii.i  the  latter  nf  ti  iileiieil  niliii-.il  eell-;,  als<i  in  a  -iiiule  l.iyer 
The  stiuiiui  /  is  (airly  dense,  ami  a  eaiiillary  ;;  is  ^eeii  in  it.     .\iii.inu  the  nohlet-eelU 
c  is  consi>ieniins  by  its  sharp  ennti^iir,  ami  by  the  exti.leil  ilmp^  i>(  snreti.m.     Tlu 
(litTerenee  in  the  ehar.icler  nf  the  seeret..ry  eells  i>t  the  Iw.i  ey^ts  is  -IriVini,',  and  may 
lie  llseU  as  showillK  the  ertetts  of  pri-s*iire  Ircun  excessive  seereti.m  in  the  l.milus  h, 
although  it  is  in  juxt.ii>.isilioa  with  Ititiilns  a,  where  there  is  ni)  evident  internal 
pies-urc.     In  tjoth  cases  there  were  i;cialimiu3  eunteiits 

To  loci  pagt  174- 


fi 


m 


CHARACTERS  POSSESSED  BY  VARIOUS  PUNCTURE-FLUIDS    1/5 

ally  possessed  by  the  particles  of  "  colloid,"  ♦  now  become  so 
larRe  Ihat  they  aggregate  into  a  solid  substance. 

In  the  case  of  the  capillary  electrometer,  where  the  electrical 
charges  of  surface  tension  come  into  play,  there  is  at  the  junction 
of  mercury  with  acid  a  double  electrical  layer,  which  is  mfluenced 
bv  an  incoming  electrical  current  (change  of  ix)tential)  when  the 
instrument  is  used.     A  loss  of  the  ix)sitive  charge  of  the  mercury 
meniscus  causes  its  surface   to  tend  to  assume  a  smaller  size 
So  with  colloids :  acco'ding  to  Bredig,  the  particles  of  colloid 
are  surrounded  by  water,  and  the  junction  line  possesses  an 
electrical  double  charge.     If  the  negative  charge  of  the  colloid 
particle  be  neutralised  the  surface  of  the  particle  will  endeavour 
To  shrink  from  the  surrounding  water,  and,  meeting  with  other 
particles  will  tend  to  associate  into  complex  groups,  tiU  by  a 
continuation  of  the  change  in  electrical  sign  we  ultimately  arrive 
at  a  point  at  which  the  aggregations  of  particles  have  attamed 
so  large  a  size  that  they  fall  out  as  a  gel. 

This  would  merely  be  part  of  what  seems  to  be  a  genera 
fact,  and  has  much  to  do  with  the  elucidation  of  problems  of 
immunity,  namely,  that  a  continuous  change  can  be  produced 
in  a  colloid  without  the  slightest  indication  to  the  naked  eye, 
as  it  were,  until  a  certain  ix)int  is  reached,  when  the  conditions 
are   so  strained   that   coagulation,   or    precipitation,   or   what 

not,  takes  place.f 

The  fact  that  electrolytes  have  something  to  do  with  tnis 
change  of  sign  demands  no  more  detailed  consideration  in  this 
place  because  the  process  is  the  same  as  described  above,  and 
it  is  sjieculation  to  consider  whether  more  chlorides  or  less, 
or  more  phosphates  or  less,  or  more  or  less  of  any  other  salts, 
do  at  any  particular  time  enter  into  the  contents  of  loculi. 

The  most  evident  feature  of  the  walls  of  these  cysts  on  micro- 
scopic examination  is  the  goblet-cells  to  which  we  have  referred 
already,  although  they  deserve  a  more  careful  consideration. 
There  is  a  decided  secretory  activity  going  on  in  all  quarters 
•  It  is  a  pity  that  the  term  "  colloid  "  should  be  applietl  to  the  material 
in  ovarian  cysts  at  the  same  time  as  it  is  applied  to  matter  in  a  .lehmte 

^'t?n  tailing  egg-white,  for  instance,  one  ,s  disturbing  the  electrical 
charge  of  ♦he  particles.  Th.s  again  illustrates  what  I  contend  .s  the 
T^Imv  in  chemical  study  of  fluids.  We  do  not  reahse  that  even  s.mple 
boiling  may  be  exerting  very  far-reachmg  effects. 


1/6 


STUDIES  IN    PUN'CTURE-rLUIDS 


-cells  nearly   all  laden  with  secretion,  others   emptied,  others 
showing   active   mitotic   figures.     The  secretion   is   presumably 
fluid,   even    though    viscid.     Can    this   secretion   become   solid 
(gel)  as  a  result  ol  the  processes  detailed  above,  or  may  there 
be  another  cause  ^       For  instance,  there  is  a  iK)ssibil,ty  that 
the  secretion  mav  continue  to  such  an  extent  within  a  limited 
sized  cyst  that  enormous  pressure  is  mechanically  exerted    by 
the  non-expanding  cvst  wall  on  its  contents.     Such  condition 
could  well  varv  in  different  loculi.  and  a  difference  m   viscidi  y 
of  adjoining  cysts  would  hinder  or  allow  expansion  of  the  neigh- 
bouring cysts.     In  this  connection,  then,  the  first  problem  is 
that  of  chscovering  whether  enormous  pressure  can  alter  the 
state  of  a  colloidal  substance,  and  if  so,  by  what  means,  and 
the  second  is  a  histological  one.  namely,  as  to  whether  there 
is  anv  evidence  of  pressure  in  these  cysts. 

In  answer  to  the  first  question,  we  may  refer  to  the  observa- 
tion made  by  Pauli,  that  the  delicate  layers  of  intercellular 
material  which  surround  cartilage  cells  may  come  to  exert 
enormous  pressures  when  they  absorb  or  gradually  give  off 
water  as  is  shown  in  the  process  of  formation  of  compact  bone. 
Thus,  some  proteid  matter  was  forced  into  steel  tubes  under 
enormous  pressure,  and  became  so  ivory-like  that  it  could  be 

worked  with  tools. 

Again,  it  has  been  computed  that  in  order  to  remove  the 
merest  suspicion  of  water  from  gelatine  which  has  taken  up 
8-4  parts  in  the  loo  of  water,  would  require  a  pressure  of  more 
than  200  atmospheres* 

We  have,  then,  to  take  the  factor  of  imbibition  mto  account 
as  a  possible  one  in  the  production  of  the  jelly-like  matter  of 
ovarian  cysts.  That  is  to  sav,  the  colloidal  matter  secreted  by 
the  goblet-cells  may  take  up  water,  and  in  so  doing  become 
so  swollen  up  in  a  given  space  that  it  has  become  of  the  con- 
sistence of  a  jelly.  Under  this  supposition,  the  particles  of 
colloid  take  up  water  like  bibulous  paj)er.  for  instance  :  each 
molecule  not  only  becomes  increased  in  size,  but  there  is  less 
water  remaining  in  solution. 

The  laws  governing  the  process  of  imbibition  of  water  by  a 
colloid  such  as  agar  have  been  expressed  in  the  following  mathe- 
matical formula  by  Hotmeistei  ;   Lei  \\'  be  the  weight  of  water 

•  Xagcl. 


t " 


i 


y 


~\ 


% 


(Z 


i^^-Tv;*^^v 


/^ 


I'lc.  12.  -From  a  Cysto  Carcinoma  Ovarii. 

Tin-  .Ir  iwiiii;  sh.iws  tUt  cpilluliuiii  coviritiH  imc  siilc  ..f  the  lil.roiH  lral>.vula,  which 
^op:ir,iU-  uiic  locuhis  from  ani.lhur.     Thi-  crowlh  is  not  iiapillifirims. 

Till-  luiimt.-  cvst  a  i-  cticloscil  l.y  Kol.l.t-cills  h,  h.  h,  in  varyins  stase>  .>f  sccrotioii. 
Sonif  ,ir.'  iiniily,  iilUirs  swolkii,  aii.l  the  ,\u.lol  sicri  titin  tan  lie  s.eii  adheriiiR  rmiml 
the  st.imata  of' the  eell-.  Ill  ^iiiiie  <>i  tile  celU  there  apjKar  to  l>e  minute  ehannoU 
(rather  too  .lark  in  the  .Irawini;),  Ihrounh  whieh  the  -ecrelion  has  to  pass  l,ef..re 
enteriiij;  the  ea\  itv  a.  f,  l>as.il  eeil-,  prolKil.ly  alniut  to  form  «oblct-cells  ;  J.  fll>rims 
tral.eviila  snpiHirlini;  the  epithelium.  This  trabeeiila  eon-ists  mainly  of  short  spindle 
cells  with  slender  nnelei,  anil  lymph.iytes  f.  ..  <■  (exuded  from  the  walls  of  the  capil- 
lary tl,  intilirate  the  lilirons  tissue,  t',  medial  cells  of  the  >tratitUil  epithelitim.  *. 
mitotic  tiuures. 

The  -pecimen  show*  the  commeiiciui;  formation  of  a  cy-t.  which  is  Hoini;  to  ex- 
pand not  only  l>y  excess  of  secretion,  lint  al-o  l.y  the  actual  growth  of  the  iiathelinm. 
In  tlii~  CISC  the  ielly-lormation  is  ilue  to  a  sul.-e<|ueut  chau^;e  in  the  oriaiual  nmciuous 
secretion. 


To  /act  pat*  t77< 


CHArACTERS  POSSESSED  liY  VARIOUS  PUXCTURE-FLUIDS    177 

absorbed  during  a  time  t,  and  P  be  the  maximum  amount  of 
turgescence  jwssible  at  the  given  temjierature,  and  D  the  thick- 
ness of  material  which  is  taking  up  the  water  in  miUimetres, 
then — 


W  -  1 


■(-■-n) 


where  k  is  a  constant. 

In  order  to  work  this  formula  out  for  the  conditions  which 
exist  in  the  case  of  ovarian  cysts,  several  experiments  would  be 
necessary.  We  will,  however,  pass  on  to  consider  the  second 
question — whether  there  is  any  evidence  of  pressure  within  X\\v 
cysts. 

In  many  examples  with  which  one  meets,  the  pressure  exerted 
by  the  contents  makes  itself  very  evident  by  the  spurt  which 
results  on  making  an  incision  into  a  cj'st,  and  it  is  remarkable 
how  flaccid  are  the  walls  in  the  case  of  some  jellies,  while  in 
other  cases  the  material  at  once  swells  out  on  cutting  the  tumour 
0})en. 

Microscopic  examination  shows  a  remarkable  richness  in 
goblet  cells,  which  consist  of  clear  cytoplasm,  and  relatively 
large  triangular  nucleus  at  the  lower  end  of  the  cell  (Fig.  10), 
while  the  upi^er  end  is  widely  dilated  and  contains  granular 
matter  presenting  somewhat  the  arrangement  of  a  network 
thickened  here  and  there  by  granules.  Some  of  the  contents 
can  be  seen  oozing  out  of  the  free  end  of  the  cell,  although  in 
other  cases  (Fig.  12)  there  seems  to  be  a  cap  of  striated  sub- 
stance, as  if  there  were  numerous  minute  channels  through 
which  the  secretion  had  to  pass.  Observations  on  living  goblet 
cells  by  Merk  showed  that  movements  may  occur  within  the 
goblet,  the  granules  becoming  darker  or  lighter  from  time  to 
time,  while  granules  come  to  the  surface  and  explode,  as  it  were, 
becoming  discharged  into  the  surrounding  medium,  and  lost 
in  it,  "  like  smoke  from  a  chimney."  This  is  well  seen  in  Fig.  10, 
and  it  indicates  that  when  the  secreted  substance  comes  outside 
the  walls  of  its  manufactory,  it  undergoes  imbibition  with  water, 
and  so  alters  its  physical  characters. 

All  these  cells  are  large  and  conspicuous,  though  here  and 
there  there  are  smaller  cells,  apparently  empty  (Fig.  12),  and 
in  other  places  again  (Fig.  iie),  the  cells  seem  to  be  devoid  of 

12 


178 


STUDIES  IN   rUXCTURE-FLUIDS 


secreting  activity  altogether.  The  presence  of  numerous  mitotic 
figures  and  the  full  distension  of  the  goblets,  however,  show 
that  a  very  striking  degree  of  secretory  activity  is  present 
throughout  the  epithelial  lining  of  these  cysts. 

Changes  in  the  nucleus  may  also  be  observed,  and  it  has  been 
supposed  by  Krausc  that  it  is  concerned  directly  with  the  process 
of  secretion.  Thus,  in  the  salivary  glands  of  cephalopoda  he 
finds  that  the  nucleus  exerts  a  ferment  action  during  secretion, 
the  ferment  being  of  an  albuminolytic  nature.  During  secretion 
the  nucleus  lies  near  the  base  of  the  cell,  and  becomes  increased 
in  size  by  nearly  20  per  cent.,  besides  losing  some  of  its  staining 
power  and  showing  granulations  to  a  much  more  noticeable 
extent  than  is  the  case  in  the  resting  cell.  Then,  again,  the 
nucleolus  may  have  something  to  do  with  the  process,  being 
more  conspicuous  and  even  multiple  or  showing  a  spiral  thread- 
like structure  during  secretion  (Nussbaum). 

The  substance  secreted  is  a  mucin,  and  one  of  its  characters 
is  still  seen  in  the  case  of  jelly-containing  cysts,  where  so  much 
glucosamine  is  found.  We  may  suppose  that  the  glycoproteid 
of  the  colloid  matter  in  the  cyst  only  differs  from  ordinary  proteid 
in  having  relatively  many  more  glucosamine  radicles  per  molecule, 
and  if  this  be  so,  it  is  not  so  difficult  to  understand  how  the 
cytoplasm  may  give  rise  to  mucin.  We  may.  for  instance,  say 
that  cytoplasm  of  goblet-cell  =  x  albumen  +  y  glucosamine, 
but  secretion  of  goblet-cell  =^  (x-z)  albumen  +  (y-z)  glucosamine, 
where  x  and  y  are  definite  but  not  knowTi  quantities,  and  z  is  a 
variable,  and  not  necessarily  the  same  in  the  case  of  the  albumen 
as  it  is  in  the  glucosamine. 

That  pseudo-mucin  as  met  with  in  ovarian  cysts  with  fluid- 
contents  is  exce*»dingly  like  "  paralbumen,"  or  paramucin  in 
chemical  compositio.-,  was  shown  by  Otori,  who  found  that  both 
})ossessed  identical  decomposition  products.  We  may  illustrate 
this  by  the  following: 


Substance. 


Author. 


Mucin  of  saliva  48-84    6-8o  I2"32    084    3r2      Hammarsten 

„        sputum  48'17    6-91  lo-8       1-42    317     ;  Muller 

Pscudo-mucin  ol"  ovarian  cysts    49'8      69  10'27  |  i'25    31 78  ]  Hamir.arsteB 

Paraiiuiciii  ol  ovarian  cysta   ...  1  5i  7(J  ,  7/6  16  7     j  1  Oy  ■■  28  69  j  M  tjukoff 

The  paramucin  contains  more  C  and  H  and  less  O. 


M 


I'lr,.    I  ?.      I'"roiii  a  Multilociilar  ()\,'iiiaii  Cyst. 

The  ~)i"i'i'>"  -liiiw-i  MM-ril  of  tin-  lonili,  wliiili  nn  ul  iliiuriiit  -i/i<.  a,  inl.iri 
litiiiii;  t|iiiluliiini  i.t  ilniilnl  iiitiii:il  -li.iin-  Tlii>  rv^l  ii.iit.iitu  ■nini-lruii^iiariiil 
iiMiUtiN  ;  '>,  A  l.iriiiT  lavilv  fillcil  with  ur.iiinl.ir  ni.illir  (-In.w-  Ji''.»n  i.f  idl-s  with 
liii;li  iHiwiri  till'  liiiim;  nii  tnlir.iiu'  li.i-  ili-^ai>iK'ar('<l  ;  r.  inttr-tid.il  li--iir  iliii'Hly 
ililillr.ittil  with  liin.iniimUar  nlN  (lyin|ili(.ivl<-*.  iiimuitiv<-li"ni'  «ilN,  ilc  i  ;  ,/,  a 
niiimti'  ly-t  >i>nliiinitiu  hi>niin;riKoii-  iiiatirial,  ami  lUvniil  i.f  hiiitii;  iiutiiliraiu'. 

iThi-  ililail<  nl  iln'  i.riL'iiial  ini<.To-|ihiit<ii;ra[ih  h:i\f  sultinil  Kfially  in  this  re- 
l>riiiliuti<>M  1      ,l/.i,'   >,i  „i,iiii. 


^J^  ^ 


I 


I'll..   I.). — Dead  and  Dyin;,'  Cells  from  a  Colloid  Carcinoma. 

Tliis  illustratis  another  nutho.!  i.f  formation  of  "  colloid  ■  nialtrial — direct  mrta- 
niorpho^i^  of  tlu-  neeroscd  ti-lU. 

ri,  II  remains  of  the  tralieeiihe  siip|iorlini;  the  cells  of  the  urowth  ;  //,  b,  cells  whose 
nuclei  are  still  visible,  though  their  shape  is  lost  ;  c,  r,  "  shailows"  of  carcinoma 
cell>  ,  ij',  .;,  liwiig  >.eilr.  (connecli\e  tiB>uc  cells,  and  other  wandering  cells).— /ms 
Hotnogen  Imm.  Cic.  4. 

To  tact  page  179, 


CHARACTERS  POSSESSED  BY  VARIOUS  PUNCTURE-FLUIDS    179 


It  must,  however,  be  admitted  that  the  substances  which 
may  be  present  in  ovarian  cysts  cannot  be  limited  in  number 
to  the  two  indicated  on  this  table.  It  is  probable  that  there 
are  many  varieties  of  "  pseudo-mucin,"  which  may  be  shown 
by  very  slight,  but  nevertheless  distinc*  ariations  in  chemical 
properties. 

The  well-development  of  these  goblet-cells  seems  to  cast 
doubt  on  the  existence  of  pressure  within  the  cyst,  whose  wall 
they  line,  but  it  nevertheless  seems  to  be  a  fact  that  even  tense 
cysts  may  show  a  perfectly  well-formed  goblet-cell  epithelium. 
This  is  contrary  to  the  well-accepted  idea  that  cavities  con- 
taining fluid  under  pressure  have  a  flattened  or  cubical  lining. 
This  may  be  so  in  many  cases,  but  it  is  certainly  not  so  in  all. 
In  Fig.  II  it  will  be  seen  that  on  one  side  of  a  small  loculus 
the  cells  are  large  and  conspicuous,  while  on  the  other  side 
they  are  low  and  cubical.  In  the  latter  loculus  the  contents 
may  have  been  tightly  packed,  but  in  both  cases  there  was 
"  colloid  "  material.     (See  also  Fig.  12.) 

In  a  section  prepared  from  a  cyst  whose  contents  were  en- 
tirely gelatinous  in  consistence  (Fig.  13),  it  will  be  seen  that 
the  cells  are  large  and  well  formed.  In  another  specimen,  where 
the  fluid  spurted  out  on  opening  the  cyst,  and  there  was  an 
adenomatous  growth  (papillary)  all  over  the  walls,  the  goblet- 
cells  are  seen  to  be  peculiarly  well  formed  (Fig.  10).  We  must 
therefore  conclude  that  the  gelatinous  material  is  due  perhaps 
to  an  excess  of  mucinous  material  in  the  secretion,  but,  never- 
theless, to  some  physical  change  which  the  secretion  has  subse- 
quently undergone.  This  change  will  be  either  one  of  imbibition 
or  will  be  due  to  a  change  in  the  electrical  properties  of  the 
material,  under  the  influence  either  of  water  or  of  some  electro- 
lyte, as  already  referred  to. 

The  question  as  to  whether  the  mucin  is  ever  derived  from 
broken-down  cells  may  be  considered  for  a  moment.  It  is  cer- 
tainly the  fact  that  if  we  search  through  the  material  in  the 
microscopic  cysts,  we  shall  find  many  desquamated  cells.  It 
may  be  presumed  that  in  the  colliquative  process  which  has 
taken  place  (Fig.  14),  special  mucinous  bodies  are  liberated, 
which  may  have  something  to  do  with  the  question.  The  fact 
that  nucleoproteid  such  as  is  met  with  in  the  substance  of 
the  nucleus  may  have  some  chemical- relation  to  the  production 


i8o 


MLMl.S   IN    llNCTlkL-l  LLII>S 


of  mucin  is  ol  mliust.  tliough  a  comparison  of  the  formula' 
of  the  two  siili>tancts  shows  that  unless  there  are  many  carho- 
hyilrate  radicles  in  the  nuc  leoproteiil  m  question,  there  will 
not  he  a  possibility  of  its  conversion  into  mucin.  The  relative 
abundance  of  degenerating,'  cells,  still  less  of  shed  cells,  as  com- 
pared with  those  whii  li  are  evidently  actively  secretin^,  is, 
however,  so  small,  that  this  factor  does  not  demand  much  serious 
notice.  The  formation  ot  "  colloid  "  material  must  be  referred 
to  physical  changes  occurring  in  the  mucinous  sccretivn  of  the 
goblet-cells  so  characti  ristic  of  these  ovarian  cysts. 

While  the  nnicinous  substance  containeil  in  ovarian  cysts 
is  usually  a  glycoproteid  of  the  ty|)e  fully  described  in  Section  I., 
Halliburton  has  described  a  case  in  which  true  mucin  is  present. 
Hanunarsfen  says  that  no  mucoids  occur  in  the  cyst  if  it  l)e 
derived  from  the  Wolffian  boily. 

The  following  analyses  by  Halliburton  will  show  the  ix-rcentage 
composition  of  the  fhiiils  from  various  ovarian  cysts  in  a  con- 
venient  form  : 


£•6 
KindofCyiU       o-l  | 

Cfl  b 


Sp.  itr. 


'1  >tal 
Solids. 


Hrotcidi. 


balU. 


Colloid 

I'apillary 

Hvdrops. 

t'  liiantc 
Hv.li'ps. 

tul  ae 
Fibre  cystic 


24 

2 


IOIO-IO38    i  28-75" 

1036  ii6'4 


IC09 
looS 


10  I 


8  8-108-3% 
102-67 


12 

63-056* 


O  '  +  ;   6-8-7% 


6-7 


The  following  details  about  cases  which  have  come  under 
one's  own  obser\ation  will  illustrate  the  characters  of  different 
t\-pes  of  ovarian  cyst. 

A  sjiecimen  of  multilocular  papillomatous  ovarian  cyst  + 
showed  the  following  varieties  of  fluid  in  different  loculi  :  (i)  a 
thin  watery  opalescent  fluid  having  a  conductivity  of  1233  (at 
25-  C.) ;  (2)  a  clear  straw-coloured  fluid  having  a  conductivity  of 
1-244  ;  (3)  a  viscid,  grumous-looking  material  with  a  conductivity 
of  I2i(),  and  (4)  a  jelly  of  dark  green  (fluorescent)  colour  whose 
conductivity  could  not  be  measured  with  the  apparatus.     There 

•  Fibrin  3-58  per  cent.  ;   globulin,  albumen, 
t  No.  6O43. 


rilARACTERS  POSSESSED  llY  VARIOUS  I'UXCTURE-KLL'IDS    iSl 

wa-i  the  merest  trace  of  chlorides  in  the  watery  Huid  (o  i)<)  i>er 
rnilU').  The  s|H'ritic  gravity  of  this  tyi>e  of  i  yst-Huid  is  usually 
.M.'i)  un<l  the  amount  of  soU<!s  2  to  5  (x-r  cent.  The  colloid 
matter  is  of  course  a  glycoproteid  in  chemical  reactions,  l)Ut 
(holesterm,  \nea.  and  fat  may  Ik>  present. 

A  s|)ecimen  of  parovarian  cysl  •  contained  a  clear,  highly 
albuminous  fluid  (29  jxjr  cent.)  of  watery  consistence  which 
was  moderately  rich  in  chlorides.  The  conductivity  at  18"  was 
I168,  corresponding  to  an  electrolyte  content  of  0-241.  The 
specific  gravity  is  below  loio  and  the  solids  amount  to  only 
I  or  2  per  cent.  This  type  of  fluid  contains  only  a  trace  of 
pseudo-mucin. 

A  unilocular  hroad  ligament  cyst  which  had  been  known  to 
e.xist  for  3.J  years  t  contained  a  brown  muddy  fluid  remarkably 
rich  in  cholesterin.  There  was  only  a  moderate  amount  of 
albumen,  and  the  conductivity  was  low.  The  ferment-content 
was  considerable  (see  Table  X.).  Leucin  was  found  in  this 
fluid  ;  a  trace  of  levulose  ;  the  a-naphthol  test  gave  no  definite 
test,  while  the  glucosan.ine  test  produced  a  well-marked  reaction. 
The  chlorides  amounted  to  yd  pro  mille.  These  in»r.-'  'a- 
mentous  cysts  usually  have  a  fairly  high  six;cific  gravity  5) 

and  contain  9  or  10  jier  cent,  of  solids. 

A  unilocular  cyst  with  dark  brown  fluid-contents  is  referred 
to  under  the  appropriate  headings  in  Sections  I.  and  II. 

An  ordinary  mulliloctilar  ovarian  cyst  J  in  a  patient  aged  21, 
contained  a  clear  watery  (slightly  mucilaginous)  fluid,  of  specific 
gravity  1009.  Proteids  were  scu  ty  in  amount,  and  were  mainly 
albumen,  protalbumose  and  hetero-albumose  being  absent. 
There  were  marked  metalbumen  reactions.  There  was  no  urea, 
no  purin  bodies  §  or  lecithin.  The  osmotic  concentration  was 
0286,  the  chlorides  were  abundant  (0145  gm.  equiv.),  and  the 
concentration  of  the  electrolytes  o-2()4.  No  ferments  were 
detected.  One  or  two  mononuclear  cells  were  alone  seen,  and 
some  stellar  phosphates  were  found. 

A  case  of  papillomatous  ovarian  cyst  with  an  opalescent  fluid 
contained  2  per  cent,  of  albumen,  6  pro  mille  of  chlorides,  and  a 


•  No.  8177. 
t  Nc.  S364. 

♦  No.  7618. 

§  I.e.  detectable  in  ^he  quantity  of  fluid  obtained. 


183 


STrr)IK>   IN    PUNCTUUE-FLUms 


conductivity  of  1075.  so  that  the  eloctrolyte-content  was  <>  .'43 
The  osmotic  coiKintiatior.  was   ^Vh).     The  usual   glycoprott-iil 
reactions  wvtv  olitairud* 

Lastly,  s|Kcial  ntiicncf  may  Ik-  made  to  a  case  t  ol  a  multi- 
locular  ovarian  cyst  wliich  contained  cholesterin,  the  typical 
cellular  elenunts,  ami  liad  a  remarkably  small  chloride-content 
(05  pro  mille),  with  a  considerable  amount  of  albumen  (25  |)er 
cent.)-     The  concentration  of  the  electrolytes  was    146. 

The  contents  of  dermoid  cysts  are  well  enough  known.  Among 
many  other  substances  they  contain  oleic,  stearic,  palmitic,  and 
myristic  acids,  cetylalcohol,  ami  cholesterm.J 

Phvsico-Chemic.vl  Ch.\r.\cters.— The  osmotic  concentra- 
tion is  similar  to,  or  most  frequently  less  than,  that  of  normal 
blootl.     The  following  values  will  Ih>  of  interest  : 

TABLE  XVIII 
Osmotic  Coscentkation  or  Ovarian  CvsT-FLUin 


Fluid. 


iKrwtinK-Poir.t        O»inolit  PrJ«Ti?ri'in 

Depre..ion.     Concntration.  AtioVphere.. 


Author. 


Cystoma  Ovarii 


Parovarian  Cyst 
Miiltilocular  Cyst 
Papillomatous  Cyht 


■54.^ 
53' 
■546 

53' 


•J93 
■286 
•294 
298 
286 
•;o3 


67 


iZangcmpister 


O.  C.  G. 


The  electrolyte-concentration  has  been  studied  by  me  in 
several  cases  where  the  cyst-contents  were  sufficiently  fiuid. 
The  results  are  given  in  the  table  on  opposite  page. 

Reference  may  here  be  made  to  a  case  reported  by  Nassauer 
in  which  an  abundant  foul-smelling  fiuid  was  discharged  per 
vaginam,  having  the  apjiearance  of  clotted  milk.  The  fiuid  was 
of  a  mucoid  character  and  contained  tiakes  of  coagulated  material, 
and  stiffened  linen.  He  states  that  this  fiuid  was  derived  from 
a  tubo-ovarian  cyst  which  l«ad  ruptured  into  the  tube.  Tlieri 
was  no  examination  of  the  fiuid  itself,  beyond  the  points  which 
have  l)een  mentioned. 


J  I.udwig  and  Zeynek. 


CHARACTERS  PObSESSED  BY  VARIOUS  rUNCTURE-FLUIDS    1 83 


2 


8 

2 
u. 

I 

u 

z 
< 


< 
> 

c 


o 
G 

.J 
W 


W  1  > 

1 

3ii|i- 

fi       i      -       •/n     -« 

tl 


.S-:i 


«       0 
7     ^ 


xf,        0 


I  i 


p  ■ 


8    i   ^ 


3,    X 


'  ilF   "  ?  ?  I  I  !  I 


wit 

a  ?     • 

z  5    - 
S 


8     ?• 


t 


8    1    = 


o 


I  «i  = 


8     I    ?    ?     P    ^ 


If. 

•^ 

:« 

U 

1 

« 

c: 

= 

« 

^ 

^ 

■4 

n 

U 

u 

u 

u 

c 

s 

1         3 

n 

0 

3 

.2 
'C 

z 

« 

c 

3 

e 

3 
S 

2 

I 


30        3S 


184 


STUDIl-S  IN    rUNCTUKE-FLUIDS 


I  tl: 


I* 


i-|! 


Hccnidtmicti'a — Zangeiiicister  i'i-coi\ls  a  case  of  atresia  of 
the  hymen  in  which  a  fluiil  was  obtained  having  an  osmotic 
concentration  identical  with  that  of  tlie  liiood  (o'joi). 

(iflatinons  masses  have  been  descrilwd  as  occurring  in  the 
ptritontum  as  the  rrsult  of  rupture  of  an  ovarian  cyst. 

An  intrrc^tini;  tnse  ol  tliis  kinil  is  rt'corclci!  hy  HiR'tor  as  occurring  in 
n  male  >u!)jict.  Tlu'  cy^t  had  arisen  Ironi  tlio  rupture  ol  an  appendix 
which  liad  iniderKOiie  t  xtrenie  c\stic  distension,  and  a  ipiantity  of  sterile 
rnucilayinous  matter  was  lound  in  the  peritoneal  cavity.  Two  other 
cases  have  been  recorded,  one  by  Fninkel  and  tlie  other  liv  Merkel. 

Tlie  p^i':ul(i-iny.\on!ii  peritonei,  when  it  bursts  into  the 
peritoneum,  may  give  a  characteristic  appearance  to  the  puncture- 
thiid.  either  from  tlie  presence  of  gelatinous  masses,  or  from  the 
presence  of  a  large  amount  of  mucinous  matter.  In  this  case 
the  fluid  will  be  tenacious,  homogeneous,  yellowish  or  whitish  in 
colour,  and  give  strong  mucin  reactions,  tieing  completely  pre- 
cipitated by  acetic  acid.  Boiling  scarcely  alters  the  appearance 
of  the  iluid,  since  iticre  is  very  little  albumen  present.  There 
is  no  pseudo-mucin,  but  paralbumen  has  been  descrilied  as 
abundantly  present  (Marchand).  The  presence  of  very  granular 
cells  may  also  be  noted  in  the  material  in  the  peritoneal 
cavity.  This  is  owing  to  the  liberation  of  the  so-called  com- 
pound granule  cells  out  of  the  cyst  cavity  into  the  peritoneal 
cavity'. 

Pancreatic  Cysts. — The  most  recent  account  of  these 
cysts  is  that  which  is  given  in  the  work  on  Diseases  of  the  Pan- 
creas by  A.  W.  Mayo  Robson  and  P.  J.  Camniidge.  They  de- 
scribe pancreatic  cysts  as  being  cither  true  or  false  (distension 
of  lesser  peritoneal  sac,  localised  collection  of  fluid  in  the 
vicinity  of  the  pancreas).  The  true  cysts  are  due  either  to 
retention  of  secretion,  to  hydatid,  to  new-growth,  to  hcTemorrhage, 
or  are  of  congenital  origin. 

The  fluid  is  of  varying  api)earance  and  consistence,  being 
sometimes  watery  and  sometimes  of  mucous  or  gelatinous  con- 
sistence. The  colour  may  be  brownish  (as  is  usual),*  or  greenish, 
or  the  fluid  may  oven  be  purulent.  The  h;emorrhagic  fluids 
probably  indicate  that  the  cyst  is  false. f     The  odour  is  stale. 

*  Liiicnsttin,  ai.so  my  own  cases. 
t   Schmidt. 


rHARACTERS  POSSESSED  BY  VARIOUS  PfNCTURE-KLUIDS    185 
Normal  pancreatic  juice  may  contain  : 


Zilwj        Scliumm.  (.lUstner. 


Spccitio  gravity     ... 
KrtCiiiMH-point  ilipression 

Water         

Dry  matter... 
Albuincn     ... 

Nilrugen     

Ash 

Orcanic  matter  soluble  in  alcohol 
Alkalescence  in  terms  of  soda    ... 


o-6i  = 

98-5  \ 
'5 

0-07 
10 

0-49: 


1009 

9^-5% 

'5 

01 
ooS 

O.Sj 

056 
0-45  , 


1007 
o'4ii' 
9S7  . 
'3 
017 
0-1 
0-56 
0-51 


i(X)7 
049^ 
9S7% 
13 
013 
008 
07 
042 


The  liuitl  contained  in  a  pancreatic  cyst,  on  the  other  hand, 
may  have  the  following  composition  : 


Specific  (iravity     ... 

Solids 

A<h 

Organic  Matter 


Albnmcn 

(ilobiilin... 

Mucin 

.Mbumose 

Urea 

Uric  acid 

Sugar 

Acetone 


lOIO  — 1020-  1060 

f  Chlorides 
Phosphates 
Sulphates      

-  .,     .^.-     'i  Calcium  and  Magne^uim 
...      » 7'9 —  'o  3       I  T  . 

'  '  ■'I  Iron        \ 

VCopper  j 

5-2^ 

0-6 


o  16 

I'raccs 

0-5 

Traces 


Fat  and  Cholosterin     0'l6 


present 

3V-3  ("O  peptone) 

Traces  0-14''; 

Trace 

None 

005 


Several  cases  of  pancreatic  cyst-fluid  which  have  been 
excunined  gave  the  following  analysis  : 


TABLE  XX 

P.\NCKEATIC    CyST-KlUILiS 


No.      Reaction.        Colour.       Sp.  Rr. 


Albu- 
men. 


Ferments. 


"    .2  '      ,  _■ 

's.=  «        1? 
it  a  '        J3  ^ 


Mucin. 


;^  a 


S309     .Mkaline     dark  1 

brown  1022  '•  S'gS^^    invertase.j 

8347   i         .,           dirty  !  trypsin  j 

j                          brown  1022  !  2-6         trypsin     i 


5744 
59>9 
4157 


dark 
straw 
bile- 
stained 


1012    I  lO'O 

1010  I 


trypsin 


trypisn 


...     i    -t-  -t- 

! 
...       i     -f    -l- 
O 

o"4oi        o 


Trace 


The  solid  material  from  two  specimens  was  found  to  consist 


1 86 


STUDIES   IN    I'LNCTUKE-FLUinS 


I 


of  fatty  acids  or  their  salts,  cholcstcrin,  and  potassium 
carbonate. 

Another  specimen,  having  a  specific  gravity  ol  1012,  con- 
tained a  niaxiniviin  (piantity  of  albumen,  but  neither  sugar  nor 
cholestcrin.  This  fluid  coagulated  spontaneously.  Proteo- 
lytic ferment  was  detected. 

The  ferment-content  of  such  fluids  is  the  most  characteristic 
])rojierty  which  they  possess.  The  following  ferments  may  be 
found  : 

Trypsin  is  generally  present,  but  may  be  absent,  especially 
in  cystic  adenoma  of  the  pancreas.* 

Pepsin  has  been   found  (Schmidt). 

Diaslcisc. — Equal  jiarts  of  starch  paste  and  fluid  will  give  a 
reaction  with  filtering  in  an  hop.r  (Schumm).  This  ferment  is, 
however,  present  in  many  fluids  ^»ee  Section  I.  Table  X.)  and  was 
not  found  in  a  case  described  by  Lillenstein. 

Lipase  has  been  looked  upon  as  characteristic  of  this  class  of 
cyst,  though  reference  to  Table  X.  will  show  that  it  has  been 
met  with  in  other  fluids. 

The  method  of  testing  for  these  ferments  has  already  been 
gone  into  sufficiently  fully  in  Section  I. 

Other  Constitients. — Chlorides  sue  scanty ;  phosphorus 
is  not  present,  f 

Hsemin  crystals  have  been  obtained  from  the  deposit  in  these 
fluids,  and  cholesterin  may  be  readily  detected  on  evaporation 
of  an  ethereal  extract  I 

*  Robson  and  Canimidgo. 
t  Scluimni. 
I  Tests  lor  Chiile^ten'ii. 

(i)  Cone.  H.,  50,  and  a  trace  of  iodine  turn  the  crystals  violet,  then 
blue,  through  green  to  red. 

(2)  Hesse-Salkowski. — Dissolve  in  chloroform  and  let  coiic.  H  SO,  n\:\ 
in.  Shake  a  little.  The  cldoroform  turns  blood-red,  then  cherry-red, 
and  the  acid  becomes  fluorescent  (:iioss-j.reen).  Four  the  chloroform 
into  a  watch-glass,  when  the  colour  passes  through  blue  and  green  to  violet. 

(3)  Deniges. — Dissolve  in  chloroform  and  add  J  vol.  cone.  H.SO,. 
Now  add  a  few  drops  of  acetic  anhydride  to  the  chloroform  layer.  A 
brilliant  red  turns  to  a  blooil  colour  in  MSO^. 

(4)  Liebermann. — Dissolve  in  acetic  anhydride.  .\dd  coiic.  H  SO,  drop 
by  drop  when  cold.  The  solution  becomes  rose-red  after  a  time  and  then 
turns  blue,  and  finally  green. 

(5)  Treat  the  alcoholic  solution  with  c -methyl  furfurol  solution  and 
run  in  cone.  HSO,.     A  rose-red  nng  appears  at  the  junction  line.     On 


CHARACTERS  POSSESSED  DY  VARIOl      PUNCTL'RE-FLLIDS    187 

Glucose  and  Gh'coproteids  were  not  present  in  Schumm's  case. 
Proteids  and  their  Derxvatives.-\\\ix\t  albumen  and  albumoses 
are  present  in  varying  amount,  the  derivatives  leucm  and  tyrosm 
are  frequently  conspicuous  *  and  may  be  found  by  simply  allow- 
ing the  fluid  to  evai>orate  in  a  small  watch-glass. 

The  variations  in  composition  have  been  suggested  by 
Lillenstein  recently  to  l>e  due  to  the  anatomical  structure  of  the 
cyst  If  there  be  a  lining  epithelium  the  contents  will  be  different 
from  those  cases  in  which  the  fluid  has  been  extravasated  (no 
definite  lining  membrane). 

The  Osmotic  Co«ce»i/r<(/i oh. -Pinkussohn  has  determined  the 
freezing-point  depression  of  normal  pancreatic  juice,  and  found 
it  to  vary  from  0-58  to  oOb"  C. 

It  will  be  seen  from  Table  XX.  that  the  fluid  from  a  pancreatic 
cv^t  owed  a  depression  of  0401°  C.  corresponding  to  an  osmotic 
concentration  of  02 17.  Another  fluid  examined  from  the  physico- 
chemical  standpoint  showed  a  conductivity  of  1430  at  244  t. 

Thyroid  CystS.-A  report  of  Hoppe-Seyler's  shows  that  one 
may  expect  to  find  mucin,  7  per  cent,  proteid,  cholestenn, 
and  calcium  oxalate.  The  dark  colour  of  these  fluids  may  be 
due  to  methffimoglobin  or  even  to  altered  bile-pigment. 

Abdominal  Cysts.-This  loose  clinical  term  refers  to  aU 

shaking,  the  fluid  turns  a  <leep  red.  giving  an  absorption  band  beginning  just 
before  E  and  ending  at  b.  (Neuberg  and  R^^-''^^^''-^^^/^'^^^^";!,  ^„  ^ 
(6)  Schifi's  reaction.-Gently  varm  with  a  httle  Fed.,  and  H(  1  in  a 
porcelain  capsule  till  nearly  .hy.  The  edges  turn  v.olet-red.  Cool.  Add 
chloroform  and  some  hy.lrochlonc  acid.  Evaporate  to  dryness  an.l  heat. 
The  whole  of  the  capsule  becomes  purple-red,  then  blue-violet,  then  d.rty 

^'T;')  Evaporate  with  H  NO ,  in  a  porcelain  dish.  A  yellow  colour  appears, 
turning  re<l  with  ammcnia.  ,      ,.,  , 

(8)  Dissolve  in  glacial  acetic  acid.  Add  acetic  anhydride  and  zi.  . 
chloride  a  rose-red  colour  with  a  greenish-yellow  fluorescence  appears, 
especially  after  a  5'  boil.     This  test  is  more  delicate  than  test  4- 

(0)  If  mixed  with  fat.  put  the  substance  in  a  sealed  tube  with  benzoic 
anhydride.     Boil  with  alcohol  and  crystallise  out   the  residue  with  ether. 

Rectangular  plates  will  be  found.  »•„.,,„  ur\ 

(10)  Hirschsohns  reaction.-A  solution  of  trichloracetic  acid  in  Htl 

gives  a  red  colour.  ,         ,         ,  < 

(11)  Obermullers  reaction.-Melt  the  crystals  with  a  few  drops  of 
propionic  anhydride.  On  cooling,  violet  colour  appears,  turning  green, 
orange,  and  then  coppei  i<-u. 

•  Schumm,  Zeehuisen. 


ISS 


STUr>Ii:S   IN    i'UNCTUKE-FLUinS 


If 


m 


these  cysts  which  are  met  with  in  tlic  abdominal  cavity,  and 
whose  natuif  has  nut  bicn  <ietcnninahle  at   the  operation. 

(1)  Two  speciiju'iis  which  liave  been  examined  were  of  this  un- 
iletermined  origin.  One  was  associated  with  a  carcinoma  recti, 
iml  had  a  specific  snivity  of  lool),  was  of  straw  colour,  neutral 
in  reaction,  and  contained  only  a  trace  of  albumen.  Mucin, 
blood,  and  cholestcrin  were  ])resent.  and  microscopic  examination 
showeil  i^roups  of  rounded  cells.  In  the  other  case  *  cholesterin 
crystals  al-.o  formed  a  characteristic  feature,  though  the  chief 
examination  made  was  of  the  cells,  which  were  mainly  red  cells 
and   polynuclear  cells  (streptococcic   infection). 

One  would  be  inciinetl  to  retjard  both  these  cases  as  having 
been  nie>enteric  cysts,  though  in  the  absence  of  post-mortem 
examinations  it  is  not  certain  that  they  were  not  retroperitoneal. 

(2)  Here  may  be  mentioned  a  case  of  cystic  Ivmphangioma 
of  the  peritoneum  which  has  been  recorded,  and  which  is  referred 
to  by  Hueter  as  being  probably  a  mistaken  diagnosis  for  pseudo- 
my.xoma  peritonei  (see  p.  184),  with  gelatinous  masses  in  the 
peritoneum. 

(3)  Another  class  of  abdominal  cysts  is  formed  by  mesenteric 
cysls,  which  form  the  subject  of  an  inaugural  dissertation  by 
Theodor  Hein  (Leipzig,  1907).  In  one  cyst  of  this  kind 
Zangemeister  found  an  osmotic  concentration  of  0-299. 

A  case  of  mesenteric  cyst  was  described  in  1907  by  Niosi, 
who  jioints  out  that  these  cysts  are  very  important,  from  their 
occasional  simulation  of  ovarian  cysts.  There  are  several  possible 
varieties:  ha;morrhagic,  chylous,  serous,  dermoid.f  hydatid, 
and  angiosarcoma,  +  and  congenital  cysts  (from  omphalo- 
mesenteric duct).  Other  forms  have  been  supjwsed  to  arise 
from  softening  o'  the  mesenteric  glands  as  a  result  of  such  in- 
fectious tliseases  as  typhoid,  tuberculosis,  etc.  The  very  ex- 
tensive literature  is  fully  quoted  by  Xiosi.  The  case  which  he 
describes  at  great  length  was  one  of  .1  cyst  containing  a  turbid, 
tenacious,  dark  chocolate-lnown  coloured  fluid  of  specific  gravity 
1040,  and  neutral  reaction.     Its  composition  was  89  per  cent. 


*  \o.  5«W3. 

t  S.   Ko--tlivy. 

*  S«'  Pfeiiiiii: — iilir  rctrot'critoiiCi'J.c  D-.rmniJ'V.l:  u.  "  InsM"  Pi=- " 
Bonn,  ic)o;.  See  al~o  H.  .Max:  Zit,  Kasmstik  der  Mesenterialzysten 
(cau>inL;  pirniciou-;  vomiting.      ■■  Inaui,'.  Diss."     Leipzig;.  I907. 


1  i 


CHAkACTr.RS  I'OSSESSED  liV  VARIOU:^  I'UNCTURL-KLUID.S    I  Sq 


water,  lo  jxt  cent,  organic  substances,  and  nearly  i  per  cent,  salts. 
Traces  of  mucus  and  peptone  were  found,  and  (r2i,^  per  cent,  of 
fat.  the  remainder  ot  the  organic  matter  consisting  of  aroumen  and 
globulin.  There  was  neither  urea  nor  sugar  present.  The  salts 
comprised  XaCl  b-b  per  cent.,  traces  of  S  and  P,  Ca  and  Fe. 
The  cellular  elements  were  granular  corpuscles  and  fatty 
ejiithelial  cells,  and  there  were  crystals  of  cholesterin.  Nio-;i 
assigns  to  this  cyst  a  congenital  origin,  connected  with  the 
Wolffian  bodies.     There  was  no  adrenal  tissue  present. 

(4)  Another  cystic  rctropcrih>neal  tumour  is  described  by 
Heyrovsky.  The  tumour  was  the  size  of  an  aflult  head,  and 
contained  mucoid  material.  It  had  existed  for  seventeen 
years,  and  was  found  to  be  a  impilliferous  cyst  contaming  goblet- 
cells  which  formed  mucus  and  then  brokr  down  into  a  colloid 
carcinoma.  Retroperitoneal  cysts  are  usually  pancreatic  or 
hydatid,  but  may  be  due  to  softening  of  a  sarcoma. 

(5)  Dermoid  cysts,  arising  by  implantation  from  a  ruptured 
ovarian  dermoid. 

(6)  Ha-morrhagic  cysts,  arising  after  traumatism. 

(7)  Hydatid  cysts. 

(8)  Omental  cysts,  which  may  be  either  h.tmorrhagic  .ir 
dermoid. 

(9)  Peripancrcatic  cvsts,  due  to  closure  of  the  foramen  of 
W'insiow  by  jieritonitic  adhesions. 

(10)  Urachal  and  allantoic  cysts  due  to  congenital  mal- 
formations— all  these  belong  to  the  class  of  abdominal  cysts. 
Ovarian  cysts,  pancreatic  cysts,  ami  the  swelling  of  a  hydro- 
nephrosis also,  strictly  speaking,  come  under  this  head.  The 
characters  of  the  fluids  n-ed  not  be  enlarged  upon  in  this  place. 

Cysts  connected  with  the  Liver.— These  have  been 
found  to  contain  cholesterin  if  they  are  connected  in  any  way 
with  the  biliary  passages.  Bile-pigment  may  therefore  be 
expected  as  well.  Such  characters  are  also  noted  when  the  cyst 
IS  connected  with  the  gall-bladder  itself.  Probably  these  cysts 
are  too  small  to  come  under  the  notice  of  the  clinician,  and  are 
usually  })ost-mortem  findings. 

Other  liver  cysts  are.  however,  met  with,  which  are  due  to 
the  breaking  down  of  neu'  gnniihs.  Hosch  records  such  a  case, 
which  he  savs  was  secomtary  to  a  cancer  of  the  stomach. 

The  only  case  of  the  kind  which  I  have  oliserved  was   one 


I90 


STUDIES   IN    ri'NXTrRE-FLUIDS 


of  breaking  down  angiosarcoma  of  the  liver  of  enormous  size 
(No.  EE4<),  Pathological  Miu-eimi,  University  of  Leeds).  The 
patient  was  aged  fifty-six,  and  he  had  had  pain  in  his  left  side 
for  four  months  before  admission  to  the  Infirmary,  and  noticed 
a  swelling  in  the  hepatic  region  only  during  three  months.  An 
orange-sized  tumour  could  be  felt,  which  fluctuated  in  the  centre. 
A  diagnosis  of  hydatid  cyst  was  made,  but  at  the  ojieration 
masses  of  blood-clot  were  found  in  the  cavity,  and  these,  on 
microscopic  examination,  were  found  to  consist  of  spindle  and 
round  cells.  It  was  not  till  the  patient's  death,  which  occurred 
soon  after,  that  the  real  nature  of  the  case  could  be  appreciated. 

Bile. — In  this  connection  it  may  be  interesting  to  mention 
that  fiilc  has  an  electroconductivity,  ranging  from  no  to  1600  10  ~ ' 
at  35 C,  the  conductivity  having  no  relation  to  the  viscosity 
or  to  the  intensity  of  the  coloration.  On  the  whole,  however, 
the  golden-colouretl  bik-s  have  a  low  conductivity,  while  the 
dark  brown  and  dark  green  biles  have  a  high  conductivity. 

The  degree  of  dissociation  varies  from  02^  too'5i,  which  shows 
that  no  constant  rule  can  be  made  from  a  study  of  this  question. 

The  fact  that  the  osmotic  and  electrolyte  concentration  of 
bile  may  vary  with  the  time  of  day  shows  it  to  be  a  fluid  with 
very  variable  characters.  Thus,  Engelman.i  found  a  steady 
rise  of  osmotic  concentration  from  0308  at  7  a.m.  to  0329  at 
2  p.m.,  after  which  there  was  a  fall  to  0-310  at  6  p.m.  and  again 
a  low  rise  to  0-319  at  8  p.m.  The  conductivity  was  -0131  at 
7  a.m.,  and  rose  to  -013S  at  2  p.m.  and  then  fell  to  -0133 
ai  ft  p.m. 

Dilute  acetic  acid  does  not  precipitate  any  body  like  the 
serosamucin  of  Umber,  and  the  u-najihthol  test,  which  has  been 
applied,  has,  however,  given  a  positive  reaction,  though  the 
gliK  osamin  test  of  Ehrlich  failed  to  give  any  reaction.  A  body 
giving  the  reactions  of  pseudo-mucin  has  not  been  found. 

Renal  Cysts.— A  few  of  those  which  have  been  examined 
have  shown  varying  characters.  The  chief  point  of  note  has 
been  the  absence  of  urea  or  uric  acid,  which  shows  tha*^  these 
substances  cannot  be  relied  on  for  making  a  diagnosis  of  renal 
origin  as  opposed  to  cysts  of  other  organs.  Indeed,  unless  the 
"cyst"  be  really  a  distended  pelvis,  i.e.  a  hvdf„nephrosis,  and 
unless  there  is  some  functioning  kidney  substance  as  well,  so 
as  to  allow  much  urea  to  be  present,  one  cannot  distinguish  a 


CHARACTERS  POSSESSED  BY  VARIOUS  PUNCTURE-FLUIDS    IQI 

renal  cyst.  In  a  cyst,*  which  proved  to  come  from  ;i  hyper- 
nephroma, there  was  found  a  considerable  quantity  of  albumen, 
which  was  probably  due  to  the  presence  of  much  blood  ;  there 
was  an  excessive  amount  of  cholesterin,  which  had  app)eared  in 
the  urine.  The  content  in  chlorides  was  very  small,  but 
there  were  copious  o.xalate  crystals,  and  also  cyst  in.  Both 
these  substances  were  sufficient  to  prove  the  probability  of  the 
cyst  being  connected  with  the  kidney.  There  was  neither  urea 
nor  uric  acid.  There  were  no  cellular  elements  to  form  a  guide. 
Another  s}iecimen  was  diagnosed  as  frc  m  a  cystic  kidney  f 
on  these  characters  :  sjiecific  gravity,  loii  ;  albumen,  i  to  4 per 
cent. ;  urea,  trace  ;  chlorides,  475  {>er  cent. ;  cone,  elect.,  0168  ; 
cone,  achlor.,  087.  In  a  case  of  hydronephrosis  ojiened  by  the 
surgeon  the  fluid  contained  i  j)er  cent.  urea. 

Reference  may  be  made  to  a  paranephric  cyst  which  was  due 
to  rupture  of  the  {x-lvis  of  the  kidney,  recorded  by  Hildebrand. 
It  is  impossible  to  pass  in  review  the  chief  }X)ints  which  will 
enable  a  fluid  to  be  distinguished  as  urine.  But  it  is  needful 
to  mention  that  there  is  occasionally  (apart  from  the  cases 
described  above)  a  necessity  for  this.  Thus,  a  fluid  was  drawn 
from  a  cystic  swelling  J  in  the  posterior  vaginal  wall,  and  it 
was  only  from  examination  of  this  fluid  that  its  origin  from  a 
dilated  ureter  that  had  become  malplaced  was  possible.  There 
was  an  abundant  effervescence,  with  sodium  hyix)bromite, 
the  reaction  was  acid,  the  chlorides  amounted  to  3-9  per  cent, 
and  the  conductivity  at  zy  C.  corresponded  to  a  concentration 
of  electrolytes  of  0158. 

The  acid  reaction  of  such  a  fluid  makes  the  diagnosis 
practically  undoubted. 

In  cases  of  hydronephrosis  the  fluid  will  vary  in  comjwsition 
according  to  the  degree  of  functional  activity  of  the  kidney  relics. 
The  siiecific  gravity  is  generally  less  than  loio,  the  amount  of 
albumen  may  vary  from  mere  presence  to  8  jKjr  cent.,  and  the 
same  is  true  of  the  salts.  The  presence  of  creatinin  and  of 
urea  or  uric  acid  would  not  necessarily  exclude,  say,  hydatid  cyst 
in  the  abdomen.  § 


»  No.  4484. 

t  No.  tV'Ss. 

C:  Record  No.  6047. 

§  Cl.  No>-.  5S69  and  6987. 


192 


STLDIF-S   IN    1>LX(  TUKE-KLLIDS 


M 


it 


In  other  words,  there  are  none  of  the  characteristic  hocUos 
present  which  would  lead  one  to  identify  the  fluid  as  renal. 

On  the  otiier  hand,  it  there  is  some  outlet  to  the  flow  of 
urine,  and  it  the  kidney  is  excreting  tolerai)ly  well,  in  spite  of 
its  functional  power  heing  much  diminished,  there  will  Ix-  some 
urea  and  other  urinary  constituents  present.  The  ciimnint  of 
urea,  however,  is  of  more  importance  than  its  mere  presence, 
Ix-cause  urea  may  he  found  in  many  other  fluids  ;  and  to  base 
a  diagnosis  of  hydronephrosis  fluid  or  urine  on  the  presence 
of  urea  might  leatl  to  fallacy.  However,  the  quantity  of  urea 
will  Mttle  the  (|ui>tion.  if  abundant.'  A  large  quantity  of  urea 
will  not  occur  excei)t  in  urine,  although  it  must  be  rememl)eretl 
that  "  no  or  very  littlf  urea  "  does  not  mean  "  no  renal  origin  " 
lor  the  fluid. 

A  case  of  congenital  cystic  kidney  which  is  of  interest 
was  described  by  Freund,  at  the  Medical  Congress  in  Halle 
(December  ii,  Kjo?).  The  case  occurred  during  labour,  and 
It  was  a  question  as  to  wliether  the  source  of  obstruction  were 
ascites,  distended  bladder,  or  kidney.  At  a  time  such  as  this, 
the  elaborate  details  which  are  referred  to  throughout  these 
pages  are  ob\iously  useless.  The  author  of  this  case  considers 
the  tumour  to  have  been  a  multilocular  cyst  of  congenital  origin, 
but  gives  no  details  as  to  the  nature  of  the  cyst-contents. 

Spleen  Cysts,  which  are  very  rare,  are  described  by  Las- 
cialfnra  is  including  (i)  hydatid,  2  cases,  (2)  serous,  (3)  sero- 
haniorrhagic — one  case  of  traumatic  origin,  but  he  gives  no 
details  of  the  characters  of  their  contents.* 

Cysts  connected  with  the  Lymphatics. — Toyosumi 
describes  a  cystic  lymphangio-endothelioma  papilliferum  which 
was  situate  in  the  abdominal  wall,  but  does  not  supi>ly  any 
information  as  to  the  chemical  or  other  characters  of  the 
contents. 

Dencks  describes  a  lymphangioma  of  the  neck,  which  con- 
tained a  whitish,  milky  fluid,  with  a  yellowish  tinge  like  lymph. 
He  states  that  other  cysts  of  similar  nature  may  contain  a  brown- 
ish fluid  owing  to  h;eniorrhage  mtc  them.  He  gives  no  other 
det-iils   about   these   fluids. 

Albrecht  refers  to  a  case  of  lyniphangif^ctasis,  in  which  numer- 

♦  Stf  ctIso  Zii-glv.nlhur  F..  Cici'  niHUiplc  urosc  Zystcn  dcr  Mil;. 
"  Inaii^.  Dis>."'     Miinchcn,  1907. 


CHARACTERS  POSSESSED  BY  VARIOUS  PUNCTURE- FLUIDS    193 

ous  little  cysts  ap|x;arcd  in  the  skin.  They  containetl  a  milky- 
white  fluid,  which  contained  some  bloo<l-cells,  lymphocytes, 
and  a  considerable  quantity  of  fat  in  the  form  of  very  minute 
drojK.  He  states  that  if  fat  was  given  by  the  mouth  it  rapidly 
apjx'ared  in  these  cysts. 

Lacteal  Cysts. — An  example  of  these  cysts  was  accidentally 
found  by  me  during  a  ix)st-mortem  examination  in  a  case  of 
suicide.  The  small  intestine  for  the  greater  part  of  its  length 
showed  numerous  white  swellings  in  its  walls,  varying  in  size, 
and  exuding  an  opaque  milky- white  fluid  when  cut  open.  The 
si»e  varied  from  that  of  a  jiea  to  about  half  an  inch  in  diameter, 
and  they  projected  into  the  lumen  of  the  intestine. 

Parotid  Cysts.* — If  these  cysts  are  connected  with  the  gland 
itself  we  should  expect  the  fluid  to  be  alkaline,  very  poor  in 
salts  (02  }>er  cent.),  and  a  low  osmotic  concentration  (0104). 
The  salts  include  chiefly  carbonates.  Whether  sulphocyanide 
is  present  in  these  fluids  or  no  does  not  seem  to  have  been 
investigated.  The  chief  feature  will  be  the  presence  rl  diastatic 
ferment. 

C]rsts  of  Bone.— -Rumjjel  refers  to  cysts  of  bone,  which 
are  usually  due  to  the  breaking  down  of  tumours,  such  as 
sarcomas.  In  one  case  described  by  him  he  comes  to  the 
conclusion  that  the  cyst,  which  contained  clear  fluid,  was 
formed  from  a  softened  enchondronui. 

The  cellular  elements  are  the  chief  characters  on  which  he 
lays  stress,  though  the  interest  to  him  is  mainly  surgical.  Such 
cysts  are  not,  as  a  rule,  likely  to  come  under  the  notice  of  the 
clinical  pathologist.  But  it  would  be  of  great  interest  to  have 
an  analysis  of  such  a  fluid,  since  it  would  afford  excellent  ideas 
as  to  the  variety  of  decomposition  products  of  new-growth 
protcid,  which  is  different  from  normal  tissue-proteid. 

A  large  cyst  was  found  in  the  cerebrum  in  a  case  by  Fahr 
of  Hamburg  (December  3,  1907).  The  walls  v»re  very  delicate, 
the  size  was  that  of  the  left  hemisphere.  There  was  no  evidence 
of  hydatid.  No  mention  is  made  of  the  contents,  the  sole 
interest  taken  in  the  case  apparently  having  been   its  clinical 


•  Unfortunately  the  only  specimen  which  I  had  the  opportunity  of 
examining,  cannut  now  be  tract-ii,  and  the  lecoril  ol  the  result  Ol  exanuaa- 
tion  cannot  be  found.  I  have  not  nad  the  opportunity  of  examining  the 
fluid  from  a  ranula. 

13 


>94 


STUDIES  IN    I'UNCTURE-FLUIDS 


symptoms.  One  would  have  preferred  evidence  as  to  the 
causalion. 

Cysts  in   connection  with  the  Cerebellum.— Cysts   in 

this  locality  can  hardlv  tver  come  under  the  notice  of  the  clinical 
pathologist,  but  for  tlu'  sake  of  completeness  they  may  In* 
referred  to.  Henschen  states  that  the  following  varieties  may 
occur  ;  dermoid  cysts,  simple  serous  cysts  (which  have  an 
eiK-ndymal  lining  and  are  related  to  the  fourth  ventricle),  cystic 
tumours,  luemorrhagic  cysts  (due  to  h;emorrhage  and  softening), 
parasitic  cysts,  and  serous  cysts,  which  are  due  to  developmental 
anomalies. 

Spermatocele.  This  fluid  is  colourless,  thin,  and  watery. 
The  siwcitic  gravity  varies  lx?tween  loof)  and  loio.  Solids,  1-3  j)er 
cent.  It  is  not  sjxjntaneously  coagulable.  Apart  from  the 
presence  of  sjxjrmatozoa,  which  is  the  diagnostic  feature,  a  re- 
action was  devised  by  Florence  for  distinguishing  sjx'rmatocele 
from  similar  fluids.  A  solution  of  iodine  (1O5)  and  jwtassium 
iodide  (254)  in  water  (30  cc),  added  to  prostatic  secretion, 
results  in  dark  brown  rhombic  crystals  (plates,  fine  needles,  and 
rosettes)  soluble  in  e.xcess  of  water,  ether,  alcohol,  acids,  and 
alkalies.     Sjwrmatocele  fluid  does  not  give  the  reaction. 

Parasitic  Cysts. — Hydatid  cysts  alone  call  for  considera- 
tion, though  their  characters  are  so  well  known  that  nothing 
new  can  be  added.  The  sjiecitic  gravity  is  low  (generally  not 
more  than  1015) ;  proteids  are  usually  absent,  while  salts  are 
abundant.*  Sugar  is  occasionally  present,  and  traces  of  urea 
may  be  exjiected,  as  well  as  of  creatin.  Succinic  acid  \  is 
characteristically  present. :J:  Microscopic  examination  of  the 
dejwsit  is,  of  course,  the  most  conclusive  evidence. 

•  In  case  No.  6897,  ^>  P'^''  mill»^  of  chlorides  were  found. 

t  To  detect  succinic  acid  in  hydatid  cysts  (Salkowski). 

In  Table  A.  No.  6,  the  concentrated  alkaline  fluid  is  treated  with  alcohol, 
and  alkaline  salts  of  succinic  .icid  will  separate  out.  These  are  dis- 
solved in  water,  the  solution  filtered  and  squeezetl.  They  are  obtained 
pure  by  adding  equal  parts  of  alcohol  and  ether  with  HCl. 

Characters. — Four-sided  needles,  melting  at  182"  C,  soluble  in  water 
and  alcohol,  very  soluble  in  ether. 

Heated  in  ..  glass  tube,  it  will  sublime.  Heated  on  platinum  foil,  it 
gives  oft  irritating  vapours. 

Neutral  lead  acetate  gives  a  heavy  crystalline  precipitate  ot  lead 
succinate 

}  ANo  present  in  hydrocele  fluid  (see  p.  1O4). 


CHARACTERS  POSSESSED  HY  VARIOUS  I'UNCTURE-FLUIDS    I95 

Mourson  and  Schlagdenhauffcn  found  a  iwisonous  ptomaine 
in  the  fluid  of  a  hydatid  cj-st. 

If  in  a  sus|>ccted  hydatid  cyst  one  finds  an  alkaline  reaction, 
no  urea  or  sugar,  and  abundant  chlorides,  this  will  not  decide 
Ix-tween  hydatid  and  hydronephrosis,  unless  hooklets  are  also 
found.  So  that  the  only  really  relial  le  sign  is  the  presence  of 
hooklets.  It  must  lie  rememlxTed.  however,  that  absence 
of  hooklets  does  not,  i(>so  facto,  exclude  hydatid. 


ti 


SECTION    IV 

THE   DIFFERENTIAL   DIAGNOSIS  OF 
EXUDATES   FROM   TRANSUDATE'" 

CoNTF.NTs.  Inductions  to  l)c  inailr  from  :  (./)  spfcificRravity.  (fc)  amount 
ot  total  protiid,  (V)  rtfrattonutry.  ((/)  viscoMty.  ie)  prost'ncc  of  sorosa- 
imicin,  (/)  Hivalta's  t»st,  (f)  prtv  net-  of  fructost-,  i-fc.  (A)  prcsonce  of 
firimnts,  (i)  ttfoct  of  oral  ailmini^tration  ot  <lruK'<.  (/)  reaction  with 
miinimc  scrum.  (A)  <vi<l<ncc  furnishi-d  by  the  chloride-  tei^iis  achlorido 
t  loctrolytts,   (/)  cytCKliagnosis. 

TiiK  attcirpts  at  ilifit-rentiation  lu'twoen  exudates  and  transu- 
dates liave  occupied  a  very  iinp«>rtant  place  in  clinical  pathology, 
and  opinions  as  to  their  value  have  varied  from  time  to  time 
according  to  failures  in  diagnosis  or  to  improved  methods  which 
prevented  recurrence  of  such  failures.  As  has  been  insisted  in 
foriner  pages,  it  is  not  possible  to  experience  uninterrupted 
successes  in  diagnosis  by  these  means  any  more  ♦'..ir  !  "^  car.  he. 
ex{K'cted  in  any  other  branch  of  medical  science.  The  evidence 
furnished  by  the  methods  to  be  detailed  must  always  be  made 
subservient  to  either  physical  signs  or  to  the  medical  history 
of  the  case  concerned. 

The  various  methods  which  are  to  be  advocated  are  not 
equally  well  known,  ami  are  deserving  of  wider  iLse,  anil  from  the 
experience  in  all  but  the  biological  test  (reaction  with  inunune 
serum)  that  has  been  obtained  from  cases  in  the  Leeds  Cieneral 
Infirmary  one  is  justified  in  collecting  the  methods  and  offering 
criticisms.  The  idea  of  using  the  electrolyte-determinations  has 
been  the  result  of  the  discovery  that  exudates  differ  essentially 
from  transudates  (us  a  rule)  in  their  achloride-electrolyte-content. 
The  following  tests  will  be  considered  seriatim  : 
Specific  gravity  ;  amount  of  total  proteid  ;  jiresence  of 
scrosamucin,  and  Rivalta's  test  ;  certain  special  tests  (for  fer- 
ments, for  acetone,  the  reaction  in  tubercular  pus,  the  reaction 

196 


EXUDATE^  AND  TRANSUPATES 


197 


witli  immiim'  strum,  the  fftert  of  administration  of  tUx^s)  ,  tlu' 
n-lation  of  chloritk-s  to  a»  hloridfs. 

A  practK.il  iiDt.'  oil  tlw  coll  ■■  tioii  of  patholoKicil  AuuIh  may  l>c 
us.ful.  Tlxflm.l  >tioul.llHtoll.-ct.-.'  intoa  |Mrl..lly  tl.-an  Loltlr.  strnli^.l 
li  mc.ssarv  l.v  tliorouKh  luatiiiK  in  an  ..vin.  Tli.'  in-.truriiintH 
usi-.l  lor  taiipiiiK  imi-.t  liavr  Inrn  Ik)iI<<I  n,  plain  watir.  an.l  tin- skin  an 
llioroiiKlily  .lismUtt.i|  as  tor  an  operation  not  only  patit-nt.  liut  optrator). 
111.-  n.cll.-  lor  piinctiirinn  is  conv.nuntly  k.pt  insi.lo  a  glasn  tuhf  o'  MUlai.U- 
iliaimt.r.  pln^K'••l  ^'t  <acli  .  n.l  with  cotton  wool,  so  that  thf  wlioli- tan  bo 
reaihlv  stiriliM.I  with  hot  air  (I)  Kst.-  Knury).  H  only  a  l.act.riolo«ical 
.■xaniinatioii  is  n.r.l.'.l  th.-  Hui.l  tan  l>o  s.nt  to  thf  liactinoloRist  m  a  small 
piict  of  n^Ass  yuUmv,  whi(  h  has  b.in  drawn  out  at  lath  end  and  sealed  up 
aftiT  hllinK- 

((«)  Specific  Gravity.  -Tlie  most  wi-U-known  characteristic 
of  transudates  is  that  their  spot  itic  gravity  is  usually  nttuh 
lower  than  tfiat  of  exudates.  Tims,  transudates  usually  have  a 
specific  gravity  of  less  than  1020,  while  exudatt>s  have  one  of 
more  than   1020.     This  is  shown  in  the  table  on  the  following 

page. 

Reference  to  the  cases  will  show  thnt  both  pleural  and  jhti- 
toneal  fluids  of  transudatory  origin  have  a  low  s|)ecific  gravity. 

The  significance  of  these  variations  may  be  attributed  mainly 
to  the  amount  of  albumen  present  in  the  tiuid.  The  more  albumen 
the  higher  will  be  the  sjwcific  gravity  ,  and  albumen  is  more 
abunilant  in  exudates  than  in  transudates.  The  relation  between 
amount  of  albumen  and  specific  gravity  ha>;  been  the  subject 
of  a  very  large  amount  of  study,  especially  by  Reuss  and  by 
Bernheim. 

According  to  Reuss,  the  specific  gravity  may  be  taken  as  a 
rough  index  of  the  amount  of  proteid,*  and  he  devised  the  follow- 
ing elaborate  formula,  which  should  enable  one  to  estimate  the 
amount  of  albumen  from  the  specific  gravity  : 

Percentage  of  albumen  =^  i  (S-iooo)-2-8,  S  being  the 
S{)ecific  gravity. 

•  Reuss  made  out  that  specific  gravity  ot 

1018  means    more    than  4  P'-'^  cent,  of  proteid. 
1015       ..  less  ,,     i'5 

loiz       ..  ..  ..     I-5--     ■■ 

loio       ,,  ,,  .-      to-1'5"  " 

1008-8    „  ..  ..     0-5-10,, 

A  series  of  relations  which  has  far  more  practical  utility,  even  if  not 
strictly  accurate,  than  any  elaborate  and  necessarily  artificial  formula. 


198 


STUDIES   IN    PUNCTURE-FLUIDS 


14 


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EXUDATES  AND  TRANSUDATES 


199 


This  comparativelv  simple  relation  ♦  was  controverted,  as 
might  be  expected,  by  Bernheim,  who  had,  by  the  aid  of  a  mathe- 
matician and  very  numerous  observations  of  albumen  versus 
specific  gravity,  been  able  to  issue  the  formula : 

Percentage  of  albumen  =  4-944<>i^  +  i-^o4<7S'- ^315  ^or 
exudates,  or  27  y  116S  - 1  :.i2^(yS^  -  275216  for  transudates,  a 
relation  which  is  obv-'i.lv  so  artiftnal  that  though  the  formula 
meets  the  observatioi  ^  of  Bernheim.  one  cannot  exi^ect  it  to 
fit  in  with  every  cast    h;'*.  will  ever  occur. 

Bernheim  came  to  u  ioUiily  difterent  conclusion,  namely,  that 
the  specific  gravity  is  no  definite  index  to  the  nature  of  a  fluid. 
The  presence  of  several  exudates  in  the  column  "  below  1020  " 
iA  the  table  will  illustrate  the  truth  of  Bernheim's  contention. 
At  the  same  time,  it  m-ist  be  admitted  that  in  a  fair  proportion 
of  cases  the  si)ecific  gravity  does  help  in  forming  an  opinion. 

As  a  matter  of  fact,  the  specific  gravity  depends  on  other 
bodies  besides  albumen,  and  the  two  cannot  be  brought  into 
relation  with  each  other,  even  if  albumen  play  the  most  important 
part  in  the  question.     Thus,  the  total  nitrogen  and  the  residual 
nitrogen  vary  with  the  specific  gravity,  and  so  also  do  the  ammonia 
and  the  purin  nitrogen.     The  parallelism  between  specific  gravity 
and  the  amido-nitrogen  and  the  nitrogen  of  the  uric  acid  prevents 
these  substances  from  helping  in  the  diagnosis,  only  that  altera- 
tion in  circulatory  conditions  such  as  occurs  in  transudates  from 
cardiac  disease  increases  the  amount  of  urea  and  amidoacids.t 
(6)  Amount   of  Total   Proteid.-This  has  long  been  re- 
garded and  rightly  so,  as  a  safe  index  to  the  nature  of  an  effusion 
into  either  abdominal  or  pleural  cavity.     Here,  as  everywhere. 
it  is  the  borderline  cases  that  present  difficulty.     The  explanation 
of  the  exceptions  is  suggested  by  Stahelin,  who  found  that  the 
amount  of  albumen  varies  with  the  nature  of  the  disease  causing 
the  efiusion  with  the  state  of  nutrition  of  the  individual,  as  well 
as  other  factors  which  need  to  be  taken  into  consideration  before 
making  any  conclusion. 

•  Compare  Chnsten's  formula  for  giving  the  percentage  of  albumen 
(a)  from  the  weight  of  a  litre  of  tluid  in  grams  at  15°  C.  (p). 
(a)=4  (P-    1006-8) 
This  formula  he  asserted  to  be  correct  within  "47  gm-  P^r  litre  (-04  _ 

per  cent.), 
t  Otori. 


i^l 


200 


STUDIES  IN   PUNCTURE-FLUIDS 


A  most  important  scries  of  observations  have  been  made 
during  recent  years  on  the  albumen-content  of  peritoneal  effusions 
by    Engliindcr   of    Vienna.     The    albumen    was    estimated    by 
weighing,   and  not   by   Esbach's  method.     This  author,  whose 
results  were  only  published  in  full  last  year,  found  that  in  hydre- 
mia the  amount  of  albumen  varies  between  03  and  05  per  cent., 
while  in  cases  of  portal  stasis  it  varies  between  i  and  1-5,  rising 
to  3  per  cent,  in  old  exudates,  or  falling  to  04  per  cent,  in  cachexia. 
In  the  last  group  of  cases,  those  due  to  portal  stasis,  the  albumen 
was  not  more  than  2  per  cent,  in  50  cases.     On  the  other  hand, 
cases  of  carcinoma  show  a  high  albumen  percentage  (up  to  7  per 
cent.),   and    in  chronic  exudative  and  tuberculous  peritonitis 
the  minimum  is  3  per  cent.     The  chief  service  afforded  by  this 
author  is  his  insistence  that  the  amount  of  albumen  must  be 
considered  in  relation  to  clinical  facts.     Thus,  in  a  case  of  cirrhosis 
of  the  liver,  if  the  albumen  in  the  peritoneal  fluid  is  2,  or  less  than 
2  per  cent.,  there  is  no  peritonitis,  while  if  there  is  much  more 
than  2  per  cent,  an  explanation  must  be  found;    and  if    the 
general  nutrition  is  not  good,  or  if  the  ascites  has  not  existed  for 
some  time,  or  if  the  abdominal  walls  are  not  tense,  then  some 
inflammatory  condition  in  the  peritoneal  cavity  must  be  looked 
for  (either  carcinomatous,  serositic,  or  syphilitic).     Whereas   if 
the  albumen-content  be  much  more  than  3  per  cent.,  and  car- 
cinoma can  be  excluded,  one  may  be  sure  that  there  is  tuberculous 
peritonitis  superadiled  to  the  liver  disease. 

The  possibility  of  excluding  tubercle  by  finding  the  per- 
centage of  albumen  to  be  less  than  3  is  an  exceedingly  useful 

point. 

Such  conclusions  were  expressed  by  Runeberg,  though  not 
to  the  same  extent  of  completeness,  when  in  iSq;  he  stated  that 
4  to  6  per  cent,  of  proteid  signified  an  inflammatory  exudate 
(tubercle  or  carcinoma),  i  to  3  per  cent,  signified  a  transudate 
from  passive  congestion,  and  01  to  03  (maximum)  meant  a  purely 
hydremic  transudate.  The  more  chronic  the  condition,  the 
less  proteid  will  there  be  in  the  fluid. 

By  bearing  such  considerations  as  these  in  mind,  it  becomes 
possible  to  diagnose  the  appearance  of  dissemination  of  carcinoma 
over  the  peritoneum  in  a  case  where  the  primary  growth  has 
merely  at  first  caused  portal  stasis.  And  further,  these  considera- 
tions will  serve  to  emphasise  the  fact  that  it  is  not  necessarily  by 


EXUDATES   AND  TRANSUDATES 


20 1 


a  single  exploratory  puncture  that  we  shall  be  able  accurately  to 
decide  on  a  diagnosis,  but  rather  is  it  by  seeing  what  changes  occur 
in  the  fluid  after  -n  interval  of  time  that  we  come  to  be  able  to 
form  a  reliable  opinion,  if  example  were  necessary  one  would 
<ite  a  case  in  which  there  was  found  at  first  a  low  albumen-content 
(25  per  cent.)  which  did  not  exclude  carcinoma,  while  the  exact 
diagnosis  remained  doubtful.  The  cytological  character  pointed 
to  stasis,  as  it  was  not  certain  whether  endothelial  or  carcinoma 
cells  were  present.  A  subsequent  puncture,  however,  showed 
a  rise  in  albumen  to  6  per  cent.,  diminished  chloride-content,  and 
alteration  in  the  cellular  characters.  At  the  necropsy  there  was 
found  a  growth  in  the  omentum  which  had  at  first  caused  merely 
back-pressure,  but  had  subsequently  come  to  the  surface  and 
commenced  dissemination  over  the  surface  of  the  pt.itoneal 
cavity. 

So  much  has  been  said,  as  to  the  methods  of  estimating  the  amount  of 
albumen,  that  there  should  be  no  need  to  refer  to  them  again.  Runeberg's 
metho<l  may,  however,  appeal  to  the  clinician  for  its  simplicity.  It  is 
carried  out  as  follows  : 

A  few  drops  of  nitric  aci<l  are  added  to  some  of  the  fluid  in  a  test-tube. 
If  a  thick  heavy  plaque  forms  that  rapidly  sinks,  this  means  inflammatory 
or  tuberculous  effusion.  If  there  arc  abundant  large  flocculi  which  sink 
less  rapidly,  this  points  to  a  congestive  transudate,  whereas  if  there  is  only 
an  opalescence,  resulting  small  flakes  appearing  only  after  a  long  time, 
this  signifies  a  hydremic  transudate.  The  limitations  of  this  method  will 
be  readily  made  out  from  what  is  being  said. 

The  table  on  the  following  page  from  one's  own  cases  will 
illustrate  the  varying  amounts  of  proteid  present  in  different 
effusions. 

As  regards  the  proteid  quotient,  which  is  obtained  by  dividing  the 
percentage  of  albumen  by  that  of  globulin,  there  is  little  to  be  said,  as  the 
ratio  cannot  be  said  to  be  characteristic  of  any  particular  class  of  effusion, 
even  if  all  the  effusions  in  a  given  patient  show  the  same  ratio  as  Halliburton 
first  described.     The  following  variations  were  found  : 

Peritoneal  fluid  from  a  case  of  Monolobular  Cirrhosis      038 

Pleural  fluid,  Chronic  inflammatory  3'5 

Tuberculous      ...  ...         ...  .••         •■•         •■•     2"b 

Simple  eHusion...         ...         ...         ...         •••         .••     o* 

The  ratio  varies  according  to  the  amount  of  globulin  present 
where  this  body  bears  relation  to  the  disease  in  virtue  of  its 
association  with  immunisation-processes.  Antitoxin  becomes 
attached  to  globuhn,  so  that  where  protective  bodies  are  formed 


202 


STUDIKS   IN    rUNCTl-KK-rLL'inS 


TAHI.K    XXII 

I'EKCENTAr.E   OK   AlBLMEN    IN    VaKIOUS    Kl.UlUS 


Below  1  ?,. 

At  or  below  2.         Heluw  3. 

lielow  4. 

Below  5 

Over  5. 

/'  Simple 

Simple            Simple 

Cardiac 

Chronic  Ne- 

/' Transu-         '!'!:•""' 
dates           ttTus.,.n 

Pleural            Pleural 
Eflusion          ElTusion 

phritis,  775 

Hjdro- 

1 

thorax 

(Kcnal) 

Pleural'                        , 

/■j 

Assoc,  with  :  Assoc,  with 

Tuberculous 

Tuberculous 

Care.               Care. 

2 (cases) 

(3  cases), 

Kxu- 

Ovarii             ( ivarii 

6-8 

>      dates 

Assoc,  with 

Care. 

1 

Ovarii,  51 

,    Kcnal 

Empyema,  8 

Thrombosis    Chronic 

Cardiac,  5-4 

i                  1 

Cardiac 

of  Portal        Nephritis 

Alcoholic 

!             1 

Ale.  Ci-rho- 

Vein                (2  cases) 

Cirrhosis 

/ 

Transu. 

'     sisol'l.iver 

Ale.  Cirrho-   Portal  t)b- 

of  Liver,  8 

Toxic     Nc- 

sis  of  Liver;     struction 

1     ''"'^^    -  1     phritis 

(2  cases)      (Runcberg) 

Syphililic 

Syph.    Cir-  | 

Cirrhosis 

rhosis    of  1 

Perito- 
neal 

(Hallibur- 

Liver 

/ 

ton) 

(Po1jakoff)| 
Carcinoma-    Carcinoma- 

Carcinoma- 

Fuberc. 

Simple 

1 

tosis                 tosis 

tosis 

Peritonitis 

Chronic  Peri- 

(2 cases)    i     (2  cases) 

(RunebergI 

tonitis,  775 

I 

dates 

Tuberculous^  Polyorrho- 
Peritonitis      menitis 
1     Chylous 
ascites 

Carcino- 
matous Pen 

tonitis,  10 
Tubercular, 

V 

1     (McHcy) 

67s 

QCdema 

Cardiac  cases 

Fluid 

Pericar- 

Tuberculous 

dial 

1 

Cysts 

1 

''  Ovarian 

Pane   r  t 

Cyst 

Cyst 

in  the  course  of  an  effusion  excited  by  bacterial  agency,  they  will 
enter  into  combination  with  the  globulin,  and  so  affect  the  proteid 
quotient.*  These  changes  have  been  noted  chiefly  in  regard  to 
the  composition  of  the  blood,  but  inasmuch  as  the  proteid  quo- 
tient is  constant  both  for  blood  and  any  effusion  that  occurs  in 
the  given  individual,  tlie  same  conditions  will  hold  in  the  case  of 

*  Glassner. 


EXUDATES  AND  TRANSUDATES 


203 


tin-  effusion.  But  when  we  reflect  that  the  urine  of  cases  of  nejih- 
ritis  may  show  a  vaiying  proteid  quotient  *  from  day  to  day,  the 
value  of  such  a  quotient  for  diagnosis  in  effusions  comes  to  require 
substantiation.  If  the  urinary  composition  varies  in  this  way. 
a  renal  ascites  may  be  expected  to  show  similar  daily  changes. 
The  relation,  too,  between  proteid  and  molecular  concentration 
cannot  be  regarded  as  having  any  prospects  of  being  of  practical 
importance. 

The  total  proteid  may  also  be  compared  wit'^  the  extractive 
nitrogen,  and  these  two  together  may  be  compared  with  the 
protcid-extractivc  ratio  of  blood-scrum.  Rzentkowski  utilised 
these  ratios  in  order  to  decide  whether  a  fluid  were  a  transudate 
or  the  result  of  endothelial  jiroliferative  processes.  If  the  ratio 
were  much  less  than  that  of  the  serum  he  would  argue  against  a 
transudatory  origin.  He  states  that  while  they  are  accumulating 
the  fluid  mainly  consists  of  salts,  while  when  the  serous  membrane 
becomes  active  the  proteid  element  enters  into  the  effusion  (an 
autochthonous  process).  In  an  exudate  we  have  the  following 
relations  :  the  dry  matter  is  less  than  that  of  the  blood-serum, 
the  total  nitrogen  is  also  less,  but  the  extractives  amount  to  still 
less  than  those  of  the  blood-serum. 

Be  these  statements  correct  or  no,  they  cannot  be  of  much 
assistance  in  the  differential  diagnosis,  merely  from  the  fact  that 
they  involve  tedious  methods  of  research  which  cannot  conveni- 
ently be  employed  for  diagnostic  purposes. 

(c)  Refractometry.— The  refractometric  observations  which 
have  been  made  by  Engl  and  advocated  strongly  by  him  as  a 
moans  of  distinguishing  between  the  two  main  classes  of  efiusion 
are  really  nothing  more  than  a  refined  method  of  albumen- 
estimations,  since  the  refractive  index  of  a  fluid  depends  very 
largely  upon  the  amount  of  albumen  which  the  effusion  contains. 
It  will  not  be  necessary  to  enter  into  any  details  of  the  methods 
of  refractometry,  simply  because  a  suitable  instrument  is  very 
expensive,  and  cannot  reasonably  be  added  to  the  instrumenta- 
rium  of  the  clinical  pathologist.  Still,  it  cannot  be  doubted 
that  the  method— given  the  instrument— is  a  very  handy  one, 
but  the  results  are  not  so  uniform  that  general  use  of  the  method 
is  advisable.     In  the  following  table,  which  is  adapted  from  a 


♦  V.  Noorden,  Noel-Paton,  Patella,  Moram. 


204 


STUDIKS   IN    PUNCTURE-FLUins 


long  series  of  observations  by  Engl,  the  numbers  represent  the 
refractive  coefficients  of  the  tUiids.     (Note  the  thickened  figures.) 


Refractive  Coffeicients  of  Various  Fluids  (Engl) 


ii 


rieura. 

Abdomen. 

Peri- 
cardium. 

Nephritic 
TranBiidales 

Subacute  Tubal 

'3379 

•3571 

'•3.37« 

Chronic  Tubal 
Interstitial 

'■3372 

I-3S72 

'3397 

Average : 

i 

•3375 

13374 

I-339S 

Cachtctic          i 

I'ernicious  Ana-mia 

••       ■•337S 

«33^ 

1-3408 

I'ransudates  1 

,  Tubcrc.  Abscess  of  Chesi . 

'337i^ 
Avtrace : 

'3365 

'•3374 

i 

•3385 
13410 

'3382 

••3398 

I'assive 

Cardiac         

I  3405 

1-3401 

Cirrhosis  of  Liver  ... 

'  ^s^s 

_.„ 

Congestion    - 
Transutlatcs 

Empliysema 

Aortic  Valve  Disease 

Average : 

1-3378 
I  3401 

'•3390 

'3392 

'•3398 

13*05 

Acute  Pleurisy 

'■3436 



— 

1  Tuberculous  Pleurisy 

'•3474 

— 

— 

;  Purulent  Pleurisy  ... 

13480 

— 

— 

Exudates 

j  Tuberc.  Peritonitis... 
Purulent  Peritonitis 

13443 
'•3479 

— 

1  Carcinomatous  Peritonitis. 

— 

13430 

— 

;  Carcinoma  Ovarii    ... 

— 

•  •3442 

— 

I   Hemorrhagic  Pericarditis. 

Average : 

Average : 

— 

1-3446 

"•3445 

'•3*59 

fl  Chronic  Hydrocephalus 

••     "•334710 

— 



Vaiious        ...- 

1 

1  Cerebrospinal  Fluid 

1  Hydrocele    ... 

'•3350 
••335° 



1                

••3429 

— 

1                

I       '335' 

— 

i                

CEdema  Fluid 

Cachectic  Nephritis 

-        '3362 
I       ''3359 

^~" 

i 

The  advantages  of  the  method  are  that  the  refractive  coeffi- 
cient, which  is  proportional  to  the  albumen-content,  (i)  is  not 
affected  by  suspended  particles,  (2)  necessitates  the  least  quantity 
of  fluid,  and  (3)  is  much  less  tedious  than  a  determination  of  the 
dry  residue  accoraing  to  Runeberg  or  a  Kjeldahl  estimation. 
Besides  this,  a  comparison  of  the  refrartive  coefficient  of  the 
effusion  can  be  readily  made  with  that  of  the  blood.  The  only 
sources  of  error  are  that  certain  substances  other  than  albumen 


EXUDATES  AND  TRANSUDATES 


205 


influence  the  rocffic  icnt  and  that  different  forms  of  proteid  cause 
variations.  While  i  i)er  cent,  albumen  has  a  coetliicicnt  of  0018, 
I  per  cent,  of  globulin  is  0020- 0023  (according  as  it  is  globulin, 
pseudo-globulin,  or  crystallin). 

((/)  Viscosity. — The  investigations  which  one  has  made  as 
to  the  viscosity  of  the  different  fluids  that  have  come  under 
observation  have  shown  very  strikingly  how  much  lower  the  value 
(as  compared  with  water)  is  in  the  case  of  transudates  than  it  is 
with  exudates.  Inasmuch  ius  the  viscosity  will  be  influenced 
by  the  amount  ot  albumen  present,  a  natural  explanation  for  the 
fact  is  found.  Probably  there  are  other  factors  to  be  considered, 
but  the  full  treatment  of  the  subject  will  be  found  in  Section  II., 
last  sub-section.  The  clinician  can  hardly  be  advised  to  purchase 
a  viscosimeter  in  order  to  assist  him  in  such  a  diagnostic  problem 
as  is  under  consideration,  so  that  more  detailed  reference  to  the 
values  found  is  out  of  place  in  this  section. 

{e)  Presence  of  Serosamucin.— The  chemistry  of  this  sub- 
stance, and  of  the  bodies  to  which  it  is  allied,  has  already  been 
fully  entered  into.  It  is  merely  necessary  to  repeat  that  the 
presence  of  serosamucin  in  a  peritoneal  fluid  is  evidence  in  favour 
of  its  being  an  exudation,*  that  is,  a  fluid  associated  with  inflam- 
matory processes  in  the  peritoneum,  t    This  fact  is  the  basis  of — 

(/)  Rivalta's  Test,  which  consists  in  adding  two  drops  of 
glacial  acetic  acid  to  100  cc.  of  distilled  water,  and  then  one  drop 
of  the  fluid  to  be  tested.  The  result,  if  the  reaction  is  "  jxjsitive," 
is  that  a  white  cloud  appears  in  the  trail  of  the  descending  drop, 
the  trail  being  of  varying  degrees  of  whiteness,  according  to  the 
severity  of  the  inflammatory  process.  Janowski  tested  this  in 
a  number  of  cases  and  obtained  uniform  results.  The  results 
obtained  in  the  Leeds  Infirmary  series  have  also  given  precisely 
concordant  results,  and  it  is  hardly  necessary  to  tabulate  the 
findings  under  such  uniform  circumstances.  Only  one  point 
would  one  emphasise,  and  that  is  that  unless  there  be  a  decided 
white  cloud,  which  increases  as  the  drop  descends,  the  result  must 
not  be  regarded  as  definitely  positive.     Often  a  faint  turbidity 


•  Rivalta. 

t  Stalulin  reports  fourteen  cases  in  which  he  examined  the  fluid  for 
serosamucin  and  found  its  presence  in  those  fluids  which  were  of  an  in- 
flammatory nature.     Eleven  cases  were  pleural  fluids ;  the  others  were  from' 
the  abdomen. 


206 


STUDIES   IN    rUNcTURE-ILUIDS 


1  . 
i 


■iri' 


will  l)c  produced  with  trans iidatos,  hut  it  will  he  found  to  disappear 
as  the  <!iop  descends.  In  a  "  positive  "  case  the  whiteness  will 
he  very  distinct,  and  the  appearance  of  ever-increasing  nuinhers 
of  white  si)ecks  which  tail  out  during  the  descent  cf  the  drop  is 
Very  striking.  The  precipitate  is,  of  course,  one  of  serosamucin, 
though  the  ])roof  of  such  hy  chemical  analysis  would  involve 
precipitation  from  large  cpiantities  of  fluid.  The  glohulin  will 
not  separate  out,  owing  to  the  presence  of  the  acetic  acid. 

ig)  Presence  of  Fructose,-  Neuhurger  and  Strauss  found 
this  hody  in  the  fluiil  in  cases  of  peritoneal  cancer,  and  in  ascites 
due  to  granular  kidney.  They  also  found  it  in  pleural  fluids 
when  not  given  hy  the  mouth.  The  oral  administration  of  fruc- 
tose usually  causes  its  reappearance  in  the  effusion. 

A<  iiTo.NK  is  said  to  occur  constantly  in  exudates. 

Widhkde's  Test.  -Wideroe  devised  a  test  which  should  in- 
form the  clinician  whether  a  given  effusion  were  due  to  tuhercle 
or  no.  The  method  may  he  carried  out  thus  :  in  a  watch-glass  a 
fe\v  drops  of  Millon's  reagent  are  jilaced,  and  on  to  the  surface 
a  sing!'  drop  of  the  fluid  to  he  tested  is  allowed  to  fall  from 
a  glass  rod.  A  film  at  once  forms  where  the  drop  meets  the 
reagent.  If  a  platinum  wire  he  now  passed  heneath  the  drop, 
and  an  attempt  made  to  lift  it  from  the  reagent,  the  drop  will 
readily  lift  up  if  the  fluid  he  of  tuherculous  nature,  less  readily 
possihle  in  the  case  of  inflammatory  effusions,  and  quite  im- 
jiossihle  (owing  to  the  hreaking  up  of  the  film)  in  the  case  of 
transudates.  In  the  case  of  the  inflammatory  effusions,  it  will 
generally  he  found  that  a  few  stahs  with  the  loop  will  break  up 
the  film  if  the  cases  he  non-tuberculous. 

From  a  number  of  specimens  examined  I  can  recommend  this 
test,  hut  absolute  reliance  cannot  he  placed  on  it,  and  in  the  case 
of  other  fluids  than  peritoneal  antl  jileural,  it  is  not  at  all  reliable. 
The  discoverer  of  the  reaction  admits  that  the  presence  of  blood 
interferes. 

Molecular  Concentr.xtion. — According  to  Rzentkowski, 
this  is  greater  in  transudates  than  in  exudates,  hut  v.  Ketly 
and  v.  Torday  deny  this. 

(h)  Presence  of  Ferments. — It  seems  reasonable  to  suppose 
that  we  shall  have  different  ferments  in  different  fluids,  varying 
with  their  causation.  In  the  case  of  transudates,  where  there 
mav  not  he  many  cell-elements,  there  will  not  he  the  cell-ferments 


ll 


EXUDATES  AN'I)  TRANSUDATES 


207 


characteristic  of  those  cells.  On  the  other  hand,  in  a  severe 
inflammatory  exudate  with  many  l)lood-celis  there  will  naturally 
be  the  ferments  associated  with  leucocytes,  a  point  which  has 
already  been  entered  into  at  some  length  (Section  I.). 

Umber  has  advanced  proof  of  the  existence  of  ferments  in 
txiidaUs  by  llie  fact  that  perfectly  sterile  exudates  treated  with 
toluol  showed  breaking-down  of  the  proteid  during  incubation. 
Total  nitrogen-determinations  were  made,  as  well  as  determina- 
tions of  the  different  forms  of  nitrogen.  These  are  shown  in  the 
following  table,  which  is  taken  from  Umber's  original  pai)er  : 


ToUl  N. 


b  1  c  d  I  e 

^^]*5"    !Di..olv.d|Ammoni.   ^I:*;?^"" 

total  N. 


Froteid 

la  -  c  X  6-»5i 


N. 


N. 


Before  Autodigestion   0-^57  gm. 
After  „  0857    „ 


5- 1 37 
5037 


■0352 
•0595 


•0*34 
•0448 


225 
412 


It  is  seen  that  the  total  nitrogen  remains  unaltered,  while  the 
uncoagulable  proteid  is  decidedly  diminished  and  the  dissolved 
non-coagulable  nitrogen  is  increased.  This  dissolved  non-coagu- 
lable  nitrogenous  matter  consists  of  primary  and  secondary  albu- 
moses,  leucin,  and  tyrosin,  which  are  therefore  increased  during 
autodigestion.  The  ammonia  is  seen  to  be  increased  almost 
twofold. 

Muller  found  that  proteolytic  ferment  only  occurs  in  the 
deposit  of  a  puncture-fluid  if  the  causation  is  inflammatory  ;  this 
is  to  be  ascribed  to  the  presence  of  proteolytic  ferment  in  the  leu- 
cocytes. The  amount  of  antiferment  which  occurs  (see  Section  I., 
p.  80)  depends  on  the  degree  of  destruction  of  the  leucocytes, 
as  otherwise  it  is  saturated  by  the  free  ferment.  Not  only  does 
the  antiferment-content  not  depend  on  these  conditions,  but 
probably  the  kind  of  albumen  in  the  fluid  will  have  something  to 
do  with  the  reaction.  If  antiferment  is  present,  the  fluid  may 
be  regarded  as  a  transudate.  If  there  be  only  a  slight  in- 
hibitory action  the  fluid  may  be  assumed  to  be  due  to  a  chronic 
inflammatory  process  and  to  contain  no  bacteria.  If  there  1x5 
no  antiferment  (i.e.  the  leucocytes  can  digest  the  gelatine  used 
for  the  test),  this  indicates  an  acute  suppurative  process,  and 
will  viuswer  even  though  the  leucocytes  m  the  deposit  be 
thoroughly  disorganised. 


208 


STUDIKS   IN    M'NCTUKK-KLUIDS 


The  (liastatir  and  invtrtiiiK  ferment  arc  often  present,  but  do 
not  show  anv  rif,'iilar  nlation  to  tlio  cause  of  the  effusion  (p.  80). 
Hut  it  may  tie  tiiat  we  must  ^o  rather  by  (juantity  of  ferment 
than  by  its  mere  presence  or  absence.  The  methods  for  estimating 
tfie  various  ferments  will  be  found  on  p.  70. 

I.ii'ASK  Ikls  been  found  by  Mammi  to  be  more  abundant  in 
exudates  than  in  transudates. 

(1)  Effect  of  Oral  Administration  of  Drugs.  -Some  in- 
teresting,' observations  wi're  made  by  I  imlolfi  at  Naples,  which 
showed  that  if  certain  drug's  were  administered  by  the  mouth 
they  ( ould  be  subsequently  detected  in  the  effusion,  and  that  if 
such  drugs  be  introduced  into  the  serous  cavity  they  will  reappear 
in  the  urine. 

It  was  found  that  while  su(  h  bodies  were  found  in  either  the 
pathological  fluid  (in  the  one  case)  f)r  in  the  urine  (in  the  other) 
in  both  exudates  and  transudates,  the  tjuuntity  of  drug  which 
reappeared  was  very  considerably  greater  in  the  case  of  transu- 
dates than  in  exudates.  The  following  list  shows  the  effect  of 
various  drugs  : 


Nalurr  of  Fluid. 

Sodi 

urn  Iodide. 

AnIipyriB. 

Salicylic  Acid 
Pyramidon. 

Purulent  exudations 



_ 

— 

Harmon  hagic  exudations 

— 

— 

— 

Tuberculous          serofibrinous 

exudate         

— 

... 

Non-tuberculous   serofibrinous  i 

exudate 

— 

... 

... 

Transudation      from      passive  ; 

congestion 

+ 

+ 

+ 

Transudation   from    liydraemia  , 

+ 

-^ 

+ 

'  Appearing  in  effu-  j        Appearing  in  urine  : 
sion  :  administered  ;      injected  into  cfl'usion 
per  OS.  I 

+  means  present ;   -  means  negative  result. 

The  reaction  with  iwtassium  iodide  was  noticed  by  Mammi. 
Fructose  given  by  the  mouth  may  appear  in  the  exudate  (see 
p.  150). 

(/)  Reaction  with  Immune  Serum.— Tedeschi  of  Genoa 
found  that  if  an  effusion  were  tested  with  immune  serum  a 
precipitin  reaction  *  would  occur  if  the  Huid  were  a  transudate, 

♦  See  also  Forssner. 


EXUDATKS   ANI>  TKANSUDATKS 


209 


while  no  reaction  oicurred  in  the  t  ase  of  an  exudate,  presumably 
owinjitothelatteriontaininK  the  necessary  eonipieiuent,  hei  ause 
ol  the  (ells  in  the  exudate. 

However,  if  thickening,'  of  the  serous  membrane  (such  as  the 
pleura)  occur,  a  transudate  may  fail  to  ^i\v  the  reaction.  Again, 
if  the  exudation  be  examined  in  an  early  stage  the  reaction  may 
come  off  owing  to  the  anti-bodies  not  having  had  tune  to  apj>ear. 
Whereas  the  reliability  of  the  reaction  is  likely  to  be  called  mto 
question,  it  must  be  admitted  that  the  practical  difficulties  in  the 
test,  involving  as  they  do  a  vivisection  licence,  will  prevent  its  use. 
The  distinction  betw  en  an  exudate  and  a  transudate  is  made 
a  very  sharp  one  by  such  a  reaction  as  this,  and  it  cannot  be 
emphasised  too  much  that  the  demarcation  line  where  exudate 
ends  and  transudate  begins  does  not  exist.  In  well-marked  cases 
the  distinction  is  easy,  but  there  are  and  always  will  be  many 
cases  which  are  not  strictly  either  the  one  or  the  other. 

The  fact  that  lecithin  plays  a  part  in  immunity  reactions, 
and  the  fact  that  lecithin  is  associated  with  pseudo-globulin  or 
with  euglobulin,  would  throw  some  light  on  the  observations  of 
Tedeschi,  and  only  brings  us  back  to  the  original  fact  that  the 
amount  of  albumen  (including  globulin)  may  form  an  index  as 
to  the  variety  of  the  fluid  being  studied. 

ik)  The  Chloride  versus  the  Achloride  Electrolytes.— 
In  the  course  of  studies  on  the  electro-conductivity  of  the 
various  fluids  which  have  been  examined,  it  was  first  noticed 
that  the  chloride-content  of  these  fluids  varied  very  greatly, 
according  to  the  causation  of  the  effusion.  As  one  would  exiH-ct, 
the  renal  drojisies  contain  a  relatively  large percentageof  chlorides, 
while  the  exudates  due  to  severe  inflammatory  change  contain 
but  few.  This  observation  led  one  to  endeavour  to  ascertain 
whether  the  other  inorganic  constituents  of  the  effusion  under- 
went any  change.  The  comparison  of  the  actual  conductivity 
of  the  fluid  with  the  conductivity  which  the  fluid  would  have 
if  only  chlorides  were  present  to  the  amount  found  by  quanti- 
tative analysis  formed  the  basis  of  the  method  adopted  for  in- 
vestigating this  point.  The  principles  involved  in  this  type  of 
"  chemical  analysis,"  and  the  difficulties  in  the  way  of  a  just 
interpretation,  with  indications  as  to  how  the  errors  can  largely 
be  obviated,  have  already  been  dealt  with  fully  (Section  I.,  under 
the  problem  of  adsorption  of  chlorine  by  egg-albumen  ;  Section 

14 


210 


STUDIES  IN    I'UN<  Tl'kE-H.UIDS 


II.,  siil)-M-<  tioti  2).     It  tliercfore  lioromes  only  necessary  tc.  ^ive 
an  account  ol  tli.'  loult^  ol>t.iine<l, 

Hefore   pro. .•.•.IniK  witli   tlu-  r.lations  .-xistinK  U'tween   the 
amount  ot  rhl(.i i.U>  compared  with  t»,at  of  ai hlonde  electrolyte>, 
it  will  W  advantageous  to  call  attention  (or  the  moment  to  the 
variations  in   chloride-content  alone  which   obtain   m  different 
classes  of  fluids.      Keleienie  to   Table  IX.  will  show  the  strikinK 
fact  that  in  tran-iidates  the  loncentration  of  chloritles  expressed 
as     grain-equivalent    (grain-molecule    jht    litre)    is    always,    or 
nearly  always,  up  to  o  I.  while  in  thuds  associated  with  varying 
degrees  of  intlammatorv  change,  or  with  disseminateil  malignant 
disease,  the  figure  harelv  reaches  oo;.     In  many  cases  the  tUu.l 
contained    in  ovarian  cysts  falls  to  a  still  lower  chloride-con- 
centration, as   will  1h>  >een  on  reference   to  Table   XIX.      'Ihe 
suIm  iitaneous  fluids  resulting  liom  cardiac  failure  or  from   renal 
ina<le(piacy  follow  the  transudates  in  respect  of  their  chloride- 
content,  though  in  some  cases  the  tlui<l  is  remarkably  free  from 
inorganic   matter.     Again,    in  the   case   of   hyJaltd  cysls.    it    is 
usual  to  find  a  high  chloride-concentration,  a  feature  which  has 
so  far  been  also  met  with  in  cases  of  cerebrospinal  liuid.     It  is 
thus  evident  that  an  estimation  of  the  chlorides  is  a  considerable 
help  in  assigning  to  a  fluid  the  diagnosis  of  its  source.     T'..at  is 
to  say,  a  fluid  obtaineil  from  the  abdomen  by  exploratory  punc- 
ture may  conceivably  Ix;  a  transuilate.  an  exudate,  an  ovarian 
cyst,  or  a  hydatid  cyst,  for  each  of  these  conditions  maybe  con- 
fused with  each  other  even  by  exin-rienced  diagnosticians.     The 
clinical    pathologist    must    utilise    every    little    possible    factor 
which  will  help  him  to  decide  such  questions  when  a  puncture- 
fluid  is  handed  over  to  him  to  issue  a  report  ujxin  it.* 

Turning  now  to  the  Table  (XXIII.)  showing  the  electrolyte- 
content  of  exudates  and  transudates,  the  first  column  is  seen 
to  give  the  chloride-concentration,  the  second  column  gives 
the  degree  of  dissociation  jwssessed  by  such  a  solution  of  NaCl, 
from  which  value  it  tecomes  possible  to  deduce  the  number  of 
molecules,  plus  ions,  in  that  solution.  The  next  column  (vi)  gives 
the  specific  conductivity,  the  values  IxMug  given  as  whole  num- 
bers raised  to  the  power  of  lo-',  since  such  values  are  more 

•  ExiKTicncc  of  tla.  bulk  of  the  precipitate  in  the  loo-cc.  tlask  enabk-. 
one  to  judge  roughly  of  the  quantity  of  the  chlorides  before  the  actual 
titration  has  been  carried  out. 


-,m-i..4^wi 


IXlhATKN   AND  TKANSUOATKS 


tl  I 


tiinKil'li-  •  This  viiluf  hiis  lH>.-n  arnvi-.l  at  by  corrcctinK  the  ron- 
(liKlivity  fimnil  Uith  fill  lfm|HT.itui.  (.ill  '  :nl  at  i.H  C  )  and 
Km  tlu'  iHKtiitaK.-  ot  all.mn.ii/'  Hk-  roir«-«iHm<linK  ronduc 
tivity  of  a  s.dution  <>l  Na(  1  ol  thf  saiiif  strtn^'th  as  the  fluid  is 
ii\svn  in  tin-  m-xt  loluniii,  and  llif  ditftri'mf  iMlwron  the  two 
f;ives  that  iMirtion  of  tli«-  total  (ondiii  tivity  whiih  is  to  In; 
asiiihed  to  the  arhlorides  Keganlinn  these  as  Na,C<),  we  can 
express  the  niimlx-rof  moU'ules,  />//(>  ions,  iht  litre  of  achlorides 
in  terms  of  Na.COj  The  last  loitiiiin  hut  one  ^ives  the  total 
concentration  ot  electrolytes,  and  the  la>t  column  expresses  the 
ratio  of  achlorides  to  chlorides. 

("omparmti  the  diffeient  classes  of  fluid,  the  strikiuK  feature 
will  he  found  to  he  that  m  the  case  of  exudations  the  ratio  named 
is  nearly  always  f^-nater  than  unity,  and,  inchrd.  is  fre<piently 
2.  .5.  or  even  uj)  to  '■.  llu'  transudates,  on  the  other  hand, 
show  a  ratio  whi(  h  is  never  more  than  o().  That  is  to  say,  the 
transudates  contain  relatively  few  aclilorid<s. 

Heforc  we  can  assert  that  such  a  series  of  olwervations  may 
l)e  relied  on  for  dii^eri'ntial  diaijnosis.  we  have  to  consider 
whether  an  explanation  for  the  hndings  can  be  found.  This 
must  l)e  sought  in  the  essential  ditference  between  a  tyf>ical 
exudate  and  a  lyfical  transudate.  The  most  conspicuous  differ- 
ence will  In?  found  in  tin-  albumen-content.  The  presence  of  so 
large  an  amount  of  all)umen  might  interfere  with  the  estimation 
of  the  chlorides  by  adsorption  or  other  circumstances,  or  the 
fact  that  nearly  all  the  tluitl  ilisapi^-ars  when  so  highly  albu- 
minous a  fluid  is  boiled  might  lead  one  to  susjK'Ct  an  intrinsic 
error  in  the  estimation.  Hoth  of  these  explanations  can  lie 
excl'ided,  however,  the  former  on  the  grounds  detailed  on  j)age 
18,  and  the  latter  on  the  ground  that  there  is  an  undoubted 
difference  in  the  chloride-content  in  exudates. 

Another  consideration  is  as  io  the  ^permeability  of  the  in- 
flamed serous  membrane  for  the  different  ions.  The  difference 
cannot  have  any  relation  to  the  relative  tonicity  of  blood-serum 
and  fluid,  since  we  have  to  deal  with  a  difference  in  the  content 
of  various  salts.  On  the  other  hand,  just  as  with  questions  of 
absorption  of  lymph  from  a  serous  cavity  there  are  three  factors 

•  Th--  notattnr,  ^,.^^i  been  fmnloved  uniformlv  throueh  this  work. 
t  The  formulx-  available  for  this  correction  will  be  found  on  pp.  100 
and  107. 


212 


STIDIES   IN    I'UNCTURE-FLUIDS 


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EXUDATES  AND  TRANSUDATES 


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214 


STUDIES   IN    PUNCTUKE-FLUIDS 


to  consider-tho  endothelial  layer,  the  capillaries,  and  the  con- 
nective tissue  ( anals-so  we  shall  have  to  consider  the  influence 
which  each  of  these  factors  can  have  in  allowing  certain  salts  to 
pass  through  and  not  others.     But  more  than  this,  we  have  to 
consider  the  effects  of  inflammation  of  the  serous  membrane, 
whereby  not  only  arc  the  jx-rivascular  lymph-spaces  filled  with 
fluid  of  abnormal  composition  and  the  endothelial  cells  under- 
going proliferation,  but  we  have  to  remember  that  the  endothelial  . 
cells  are  being  cast  off  into  the  fluid,  and  that  angiogenic  cells 
as  well  as  histogenic  cells  are  making  their  way  into  the  fluid  in 
question.     In  the  case  of  carcinomatosis  of  the  peritoneum,  too, 
there  is  also  the  discharge  into  the  fluid  of  the  carcinoma  cells  with 
the  products  of  their  disintegration  or  the  products  of  metabolism 
of  those  carcinomatous  cells  which  have  not  been  shed. 

According  to  experiments  made  by  Hamburger,  artificially 
induced  inflammation  or  injury  short  of  inflammation  of  a  serous 
membrane  does  not  cause  any  change  in  the  phenomena  of 
absorption  from  that  cavity,  so  that  we  may  presume  that  the 
problem  to  be  solved  is  the  same  whether  we  are  dealing  with 
the  ordinary  three  factors  above  referred  to  or  with  the  same 
factors  in  a  state  of  disease.  Such  experiments,  however,  as 
Hamburger  jxjrformed  (injection  of  strong  salt  solutions  after 
chemical  and  thermal  injury  to  the  peritoneum)  do  not  affect 
the  probability  that  the  cellular  elements  which  are  discharged 
into  the  peritoneal  cavity  when  the  membrane  is  inflamed  will 
cause  a  change  in  its  composition. 

Hamburger  in  a  sories  of  experiments  on  the  influence  of  pres-sure 
on  absorption  from  the  connective-tissues,  came  to  the  conchision  that 
increased  pressure  does  not  allow  proportionately  as  much  NaCl  to  pass 
out  from  the  bloo<l  into  the  tissues  as  does  a  lower  pressure.  The  pro- 
cess seems  to  him  to  be  purely  physical  and  to  depend  on  the  lower  chlonde- 
concentration  in  the  tissues  to  that  in  the  blood.  If  other  salts  are  present 
in  the  tissues,  these  will  pass  into  the  blood,  while  the  NaCl  passes  out. 
This  is  probably  in  accordance  with  Hamburger's  principle  that  unless 
an  ion  passes  out  of,  say,  a  red  cell,  another  ion  cannot  enter. 

Perme^biiitv  OF  Cells  to  loNS.-Urea,  sodium  chloride, 
and  dextrose  were  found  by  Lazarus-Barlow  to  pass  through 
an  artificial  membrane  with  distinctly  varying  velocities,  and 
Roth  proved  that  the  same  fact  holds  good  for  the  livmg 
peritoneum,  urea  passing  through  most  rapidly,  xvhiie  dextrose 
passed  through  least  rapidly  of  the  thiee.     Followmg  on  these 


EXUDATES  AND  TRANSUDATES 


ais 


observations,  an   extensive    series  of    researches  on   the    per- 
meability of  red  cells  for  the  various  ions  were  made  by  Hedm, 
Gryns,  and  Overton,  and  then  by  Hamburger.     Leaving  the 
organic  substances  to  which  red  cells  are  permeable  or  no  out 
of  count  for  the   present,  we  find  that  red  cells  are  quite  tm- 
permeable  for  Ca",  Sr^  Ba",  Mg',  but  permeable  for  NH,.'  free 
acids,  and  free   alkalies.     Leucocytes  are    permeable   for  CI', 
SO,',  and  NO.,,  and  if  the  solution   in  which  they  lie  contain 
col  they  will  lose  CO3'.     This  is  an  important  fact,  for  it  shows 
us  that  if  CO,  is  present  in  an  effusion  the  result  will  be  the 
passage  of  carbonates  from  the  ceUular  elements  in  it  into  the 
fluid,  and  the  absorption  of  CI  and  achlorides  other  than  CO3 
into  the  cellular  elements  from  the  fluid.    The  result  will  be 
that  the  concentration  of  the  carbonates  will  rise,  and  that  of  the 
chlorides  fall.    The  analysis  of  pus-cells  (see  p.  146)  shows  that  the 
achloride  salts  other  than  carbonates  are  not  abundant,  so  that 
the  passage  of  carbonates  out  will  have  more  effect  on  the  electro- 
lyte-content than  will  the  passage  of  the  other  electrolytes  into 
the  cells  (loss  from  tWe  fluid).     This,  then,  in  s  :h  a  fluid  as  a 
purulent  exudate  would  account  very  well   for  the  findmg  of 
preponderance  of  achloride  over  chloride  electrolyte.     In  those 
inflammatory  fluids  where  actual  pus  is  not  present,  there  may 
be  nevertheless  enough  cellular  elements  to  account  for  the 
phenomenon,  and  in  the  case  of  malignant  effusions  and  tuber- 
culous effusions  where  there  is  an  out-pouring  of  red  cells  (limited 
in  amount,  it  is  true),  the  permeabUity  properties  of  the  latter  wUl 
also  assist  in  the  production  of  the  ratio  which  is  under  discussion. 
It  may  be  urged  that  we  do  not  know  that  CO..i  is  present  in 
a  peritoneal  fluid,  except  in  so  far  as  may  be  assumed  from  the 
alkaline  reaction. 

When  we  come  to  consider  the  influence  which  the  endo- 
thelium will  have,  we  come  upon  less  known  ground.  As  far  as 
the  researches  of  Hober  show,  CI  is  much  more  readily  taken  up 
than  any  other  salt,  but  this  wUl  not  afford  any  explanation  01 
the  preponderance  of  NaCl  in  a  transudate.  The  rate  of  migra- 
tion of  the  ions  will  not  help  here,  excepting  that  CO3  has  a 
rather  slower  rate  (O5)  than  the  others  (70-73). 

Just  as  there  is  a  difficulty  in  assigning  a  proi^er  place  to  the 
endothelial  laver.  so  there  is  a  difficulty  in  discovering  what  may 
be  the  influence  of  the  endothelial  walls  of  the  capillaries,  or. 


I 


2l6 


STUDIES   IN    I'CNCTURE-FLUIDS 


indeed,  the  intcrcelluUtr  substance  of  the  endothelial  lining  of  the 
peritoneum.  The  influence  which  the  connective  tissue  canals 
exert  is  the  same  as  that  exerted  by  the  endothelium,  according 
to  the  exiKMiments  of  Starling.  That  is  to  say,  they  readily 
take  up  isotonic  NaCl  solutions.  If  we  consider  a  large  vessel 
containing  NaCl  and  albumen,  separated  from  another  smaller 
vessel  by  a  permeable  membrane  containing  a  similar  salt  solu- 
tion, but  no  albumen,  then,  according  to  Starling's  simile,  the 
albuminous  fluid  will  attract  water  from  the  non-albuminous 
side,  with  a  resulting  increase  in  the  concentration  of  that  fluid. 
Some  NaCl  will  therefore  diffuse  into  the  larger  cavity,  and  the 
osmotic  iMessure  of  the  smaller  will  fall.  The  large  cavity 
represents  the  blood,  and  the  sma'l  one  represents  the  lymphatics 
and  the  j^entoneum.  The  difference  in  the  amount  of  proteid 
will  cause  a  difference  in  the  water-attraction  of  the  two  sides, 
and  cause  NaCl  to  leave  the  fluid  and  enter  the  blood.  In 
exudates,  where  the  albumen-content  will  about  equal  that  of  the 
serum,  there  will  therefore  be  no  passage  of  NaCl  from  exudate 
into  the  blood  ;  in  transudates,  on  the  other  hand,  there  should 
be  a  passage  of  NaCl  into  the  blood,  which  will  bring  us  to  the 
conclusion  that  in  the  exuilate  there  is  more  NaCl  in  the  fluid 
than  there  is  in  the  transudate.  This  apparent  contradiction 
is,  however,  to  te  explained  thus  :  that  (i)  in  the  effusion  there 
has  been  a  reverse  of  a  normal  process,  for  filtration  with  diffu- 
sion and  a  change  in  osmotic  pressure  causes  fluid  to  be  poured 
out  into  the  serous  cavity.  The  movement  of  ions  is  in  the 
opiwsite  direction.  So  the  result  is  that  in  a  transudate  there  will 
be  more  ready  passage  of  NaCl  into  the  cavity.  In  the  exudate, 
on  the  other  hand,  where  there  is  a  process  of  secretion  on  the 
part  of  the  serosa,  this  reverse  flow  of  fluid  has  nothing  to  do 
with  mere  filtration  or  diffusion.  (2)  In  the  renal  transudate  it 
is  the  excess  of  NaCl  which  is  causing  outjwuring  of  fluid  into 
every  available  space,  in  order  to  procure  its  solution  isotonically 

with  the  blood. 

Probably  it  is  here  that  the  explanation  of  the  differences  in 
chemical  composition  is  to  be  found :  in  inflammation  there  is 
a  secretion,  in  transudation  there  are  merely  i)hysical  factors. 
And  added  on  to  that  we  have  the  excess  of  cellular  elements 
in  the  exudate  as  compared  with  the  transudate,  a  tact  which 
affords  full  play  for  the  varying  permeability  of  ions  to  cells  to 


EXUDATES  AND   TRANSUDATES 


217 


take  place.  It  may.  however,  be  argued  that  in  the  process 
of  inflammation  the  endothehum  of  the  vessels  and  of  the 
serosa  as  well  as  its  jiermeability  for  ions  is  altered,  while 
the  increased  pressure  in  the  capillaries  of  the  inflamed  jieri- 
toneum  will  also  affect  the  osmotic  processes. 

To  what  extent  the  permeability  of  carcinoma  cells  may  have 
an  influence  in  the  question  of  carcinomatous  effusions  having 
an  increased  achloride-content  it  is  not  possible  to  decide,  in  the 
absence  of  any  exiieriments  on  the  permeability  of  such  cells 
for  the  various  ions.  But  probably  their  influence  is  rather 
in  the  direction  of  their  chemical  composition,  since  so  many  of 
them  are  shed  and  in  a  state  of  disintegration.  Here  the  fact 
that  we  have  more  potassium  salts  than  sodium  salts,  and  more 
phosphates  than  chlorides  in  the  cells,  will  serve  to  indicate 
a  possible  explanation.  The  chemistry  of  carcinoma  and  sar- 
coma tissue  is.  however,  not  well  enough  known  to  enable  us  to 
base  any  opinions  upon  this  aspect  of  the  question. 

In  conclusion  it  may  be  said,  then,  the  difference  in  electro- 
lyte-content of  transudates  from  exudates  is  sufficiently  funda- 
mental to  allow  of  its  forming  a  basis  of  diagnosis  in  practical 
work.  At  the  same  time  it  nmst  be  insisted  that  this  is  not 
necessarily  an  infallible  test,  and  exceptions  are  sure  to  be  met 
with  ;  indeed,  in  some  of  the  tabulated  cases  there  are  such 
exceptions  recorded  (Xos.  8344.  6()77,  6662).  An  interesting 
example  of  this  kind  is  afforded  by  No.  8358,  pleural  fluid.  This 
was  a  case  of  apparent  hydrothorax  and  hydroperitoneum  due 
to  renal  disease.  The  ratio  is  seen  to  be  109,  which  would  be  an 
exception  to  the  rule,  since  the  renal  fluid  should  be  transudatory. 
The  explanation  is  that  the  pleural  cavity  had  been  filled  with  an 
inflammatory  fluid  owing  to  a  complicating  inflammation  with 
adhesions.  In  6667  and  6662  the  inflammatory  character  of  the 
pleural  fluid  is  not  certain.  But  the  occurrence  of  such  excep- 
tions may  be  courted,  from  the  scientific  standjwint.  as,  in  all 
probability,  when  the  explanation  for  such  exceptions  is  found 
we  shall  have  obtained  a  deeper  insight  into  the  constitution  of 
body-fluids  under  certain  conditions  than  was  Ijefore  possible. 

(/)  Cytodiagnosis. — This  section  of  the  differential  diagnosis 
problem  is  dealt  with  in  the  succeeding  section. 


SECTION    V 


In 


CYTODIAGNOSIS 

puncture-rtuids-Artificial  scheme  for  cytod.agnos.s-The  chenu.try 
of  the  cell  elements. 
The  study  of  the  cellular  elements  in  exudates  and  transudates 
was  not  prosecuted  systematically  until  after  the  publication 
of  the  work  of  Widal  and  Ravaut  at  so  recent  a  date  as  1900. 
Their  observation,  among  many  others,  that  tuberculous  effusions 
were  associated  with  an  excess  of  lymphocytes  m  the  fluid 
aroused  instant  and  widespread  interest  in  the  subject,  and  the 
literature  on  "  cytodiagnosis  "  has  steadily  come  to  assume 
exceedingly  formidable  proportions. 

It  may  perhaps  be  said  that  the  enthusiasm  which  ascribed 
to  this  study  an  almost  pathognomonic  importance  has  now 
simmered  down  into  a  more  sober  realisation  that  lymphocytes 
may  be  in  excess  in  other  fluids  than  those  excited  by  tubercle 
bacilli  while  even  the  latter  may  at  certain  stages  be  associated 
with  excess  of  polynuclear  leucocytes  m  the  fluid. 

A  possible  explanation  for  the  undoubted  discordance  in  the 
results  obtained  by  cytological  examination  of  puncture-fluids 
r^ay  be  found  in  the  objection  made  by  Sahli  that  the  fluid 
obtained  by  aspiration  does  not  necessarily  accurately  represent 
the  cellular  characters  of  the  fluid,  owing  to  the  inevitable 
influence  of  gravitv  on  the  deposition  of  the  cells  whose  specific 
gravity  shows  variations.  The  ceUs  in  the  deepest  layers  would 
cscajie  the  exploratory  puncture. 

218 


CYTODIAGNOSIS 


219 


Again,  when  the  cellular  elements  become  entangled  in  a 
fibrinous  coagulum,  it  docs  not  necessarily  follow  that  all  the 
varieties  of  cells  will  become  entangled  in  equal  projxjrtions. 

Lastly,  it  must  be  admitted  that  the  cellular  characters 
found  to  exist  in  a  fluid  really  only  represent  the  condition  of 
that  fluid  at  the  moment  of  tapping,  and  a  subsequent  observation 
may  reveal  an  entire  change  in  the  cytological  picture. 

In  view  of  the  fact  that  so  much  has  been  written  on  the 
facts  of  cytodiagnosis,  it  is  not  projwsed  to  enter  at  all  fully  into 
the  various  phases  of  the  subject,  and  it  is  rather  with  the  view 
of  suggesting  that  the  cellular  characters  of  a  fluid  may  throw 
light  on  its  chemical  characters  that  the  subject  is  at  all  ap- 
proached. The  quite  recent  (iqo8)  publication  of  a  monograph 
on  cytodiagnosis  by  Koniger  renders  a  detailed  description  the 
more  superfluous,  as  that  work  can  be  thoroughly  recommended 
for  its  clearness  and  comprehensiveness  to  all  who  are  interested 
in  the  subject. 


METHODS   OF   PREPARATION   OF  THE   CELLS 

The  deposit  from  a  fluid  may  be  examined  both  unstained, 
and  after  staining  by  various  methods.  It  is  advisable  to  com- 
bine the  two  methods,  as  much  can  be  learnt  from  the  appearance 
of  the  cells  in  a  fresh  condition  that  would  be  lost  during  the 
process  of  staining,  especially  as  regards  carcinoma  cells.  As 
regards  staining  methods,  Jenner's  stain,  answering  as  it  does  all 
purposes,  is  most  to  be  recommended.  The  exact  formulae,  etc., 
of  this  or  other  stains  will  be  found  in  several  exhaustive  works 
that  have  appeared  on  blood-cell  technique. 

The  Collection  of  the  Deposit.— In  the  case  of  fluids 
which  do  not  coagulate  spontaneously,  the  ceUular  elements 
separate  out  on  standing,  and  are  readily  pipetted  off.  it  is,, 
however,  advisable  to  prevent  any  risk  of  decomposition  of 
the  very  delicate  cells,  by  centrifugalising  the  fluid  as  soon  as 
possible.  Dilution  with  citrate  of  soda  before  centrifugalisa- 
tion,  pouring  off  the  supernatant  fluid,  and  shaking  up  again 
with  saline,  with  re-centrifugalisation  (after  the  method  of 
Sir  A.  E.  Wright  for  white  cells),  can  be  highly  recommended, 
since  the  removal  oi  the  albumt n  in  this  way  greatly  facilitates 
staining.    The  risk,  however,  of  breaking  up  degenerate  endo- 


220 


STL'DIES  IN    PUNCTURE-FLUIDS 


If' 


thflial  cells  or  vacuolated  carcinoma  cells  has  to  l>e  borne  in 

mintl. 

Incases  where  a  coagulum  has  formed  before  the  fluid  comes 
to  hand  for  examination,  it  may  suffice  to  take  a  small  snipping 
of  the  coagulum  and  examine  it  fresh  (no  diluting  fluid  to  lie  used). 
If  the  result  is  not  satisfactory,  some  of  the  coagulum  may  be 
stirred  about  in  a  small  quantity  of  fluid  placed  in  a  watch-glass, 
using  a  platinum  wire  as  stirrer.  The  fluid  may  then  be  centri- 
fugaliscil.  The  risk  is.  of  course,  that  the  dei)osit  will  not  then 
exactly  represent  the  characters  of  the  deposit,  owing  to  uneven 
separation  of  the  cells.  The  unstained  snipping  may  then  be 
used  as  a  contP'l. 

Preparation  of  the  Film.— For  fresh  si^ecimens  a  drop  is 
simply  covered  with  a  cover  and  cxamineil  with  the  Jth.  For 
stained  preparations  a  thin  film  is  spread  on  a  slide,*  preferably 
albumenised,  and  allowed  to  dry  on  a  shelf  arranged  on  the  paraffin 
oven.  A  saturated  solution  of  Jenner's  stain  (Grubler,  e.g.)  in 
anhydrous  acetone-free  methyl  alcohol  (Merck)  is  prepared  in  a 
well-fitting  stoppered  bottle,  and  a  couple  of  drops  are  allowed 
to  fall  on  the  film.  A  Petri  dish  is  convenient  as  a  cover  for  the 
ordinary  3-inch  slide.  After  two  minutes  t  the  slide  is  gently 
washed  in  distilled  water  till  the  pink  colour  apj^ears,  and  dried 
by  the  application  of  "'  Huffless  "  blotting-pajier,  followed  by  a 
momentary  warmth  in  the  hollow  of  the  hand  over  a  Bunsen 
flame.  The  preparation  is  now  ready  for  examination  with  an 
oil-immersion  lens.  The  staining  effects  are  illustrated  on 
accompanying  plates. 

Though  special  works  on  blood-cell  technique  will  mention 
the  precautions  needed  in  the  use  of  Jenner's  stain,  besides 
explaining  the  chemistry  of  the  stain,  it  may  be  mentioned  (i)  that 
the  stopi^er  of  the  bottle  must  be  "  turned  off  "  when  not  in  use  ; 
(2)  that  no  time  must  be  lost  in  applying  the  Petri  dish  after 
pouring  on  the  stain  ;   (3)  that  the  time  of  staining  must  not  be 


ill 


*  Slides  are  much  preferable  to  cover-glasses  (or  cytological  and  bac- 
tirioloKical  work  of  all  kinds.  The  whole  slide  is  covered  with  dejiosit, 
■save  a  strip  at  one  end.  which  is  left  free  for  the  fingers.  One  slide  will  then 
ha\  e  as  much  on  as  many  coverslips.  and  a  sliding  stage  enables  the  work 
to  be  done  with  much  less  labour  than  is  involved  in  using  several  cover- 
j-lips. 

t  A  two-minute  sand  time-glass  is  most  handy. 


CYTODIAGNOSIS 


221 


exceeded  ;  (4)  that  the  washing  must  be  carefully  watched  till 
the  colour  just  apjx^ars  ;  (5)  that  no  time  must  be  lost  in  drying. 
Another  method,  recommended  by  Jagri,  is  to  add  2  ix;r  cent, 
formalin  to  the  fluid  whose  cells  are  to  be  examined,  centrifuge 
ofi  the  deposit  after  a  few  hours,  and  then  stain  with  a  freshly 
jirepared  Giemsa  solution  in  glycerin  anil  methyl  alcohol.  The 
cells  should  be  examined  while  in  the  stain. 

The  Results  afforded  by  Cytodiagnosis.— The  cells  of 
a  puncture-fluid  may  be  either  enumerated  in  a  counting-chamlier 
or  may  l)e  subjected  to  a  "  differential  count."  Sometimes  it 
is  advisable  to  jierform  both  forms  of  counting.  The  second 
count  is,  however,  much  more  generally  useful,  especially  as  by  its 
means  we  can  watch  the  progressive  changes  in  the  cellular 
constitution  of  an  effusion— changes  which  occasionally  afford 
valuable  prognostic  indications.  The  insight  into  diagnosis 
is  indicated  by  the  following  considerations:  If  inflammation 
suj^ervenes  during  the  course  of  a  passive  accumulation  of  fluid, 
the  cytological  picture  will  become  completely  changed,  as  will 
be  shown  later  ;  or  if  recovery  is  taking  place  from  an  inflam- 
matory effusion  another  change  will  be  found  to  take  place  in 
the  relative  proportion  of  the  cells  ;  or,  yet  again,  if  inflamma- 
tion arises  in  the  neighbourhood  of  a  serous  membrane  into 
which  there  is  already  an  effusion  from  jmssive  causes,  the 
cellular  elements  will  be  altered,  even  though  the  inflammation 
has  not  affected  the  serous  membrane  itself. 

It  will  be  necessary  to  refer  to  these  points  again,  but  to 
avoid  repetition  it  will  be  more  satisfactory  to  discuss  each  class 
of  cell  that  may  occur  in  a  puncture-fluid,  and  its  relations  to 
disease,  than  to  discuss  the  diseases,  with  reference  to  their 
cytological  characters,  or,  as  it  is  termed,  their  "  cytological 
formula." 

A  series  of  researches  made  by  Heinz  in  1900  throw  much 
light  on  the  occurrence  of  different  cytological  formulas,  although 
no  particular  notice  seems  to  have  been  hitherto  taken  of  his 
work.  This  observer  studied  the  effects  of  artificially  induced  in- 
flammation of  the  peritoneum  in  rabbits  (injections  of  emulsions 
of  turpentine  and  of  iodine).  The  result  was  an  accumulation  of 
leucocytes  beneath  the  endothelium  at  the  spots  at  which  the 
irritation  came  in  contact.  Little  raised  masses  consisting  of 
fibrin  filaments  (due  to  coagulation  of  outpoured  serum)  in- 


222 


STUniKS  IN    PUN(TURE-FLUII)S 


filtrated  by  thise  leucocytes,  aj^iieared.  and  subsequently  fibro- 
blasts  replaced  the  coagulated  material,  which  was  still  covered 
by  an  intact  serosa.     As  the  inrtammation  proceeded,  however, 
the  endothelial  cells  l)egan  to  proliferate  and  assume  a  more 
cubical  shaiH',  their  cell-body  Ix-came  more  granular,  and  their 
nucleus  larger  and  richer  in  chromatm,  with  development  ot 
mitotic    figures.      Delicate  strands   of    cells    and   membranous 
structures  made  tluir  apiH'arance  still  later,  until  the  tag-like 
processes  of  a  cor  vtllosim  were  produced,  and  these  tags  were 
also  covered  by  several  thicknesses  of  cubical  epithelial  cells 
showing    numerous   mitotic    figures.     These    young   embryonic 
cells  formed  part  of  a  new  mucoid  tissue  which  was  vascularised 
from  the  serosa  vessels.        lie  liberation  of  such  cells,  as  well  as  a 
liberation  of  i)olvnuclear  cells,  would  give  a  distmctive  character 
to   the  e.Kudate,  varying  according  to  the  stage  at  which  the 
inflammatorv  change  had  reached. 

The  exact  course  which  the  inflammatory  processes  is  going 
to  take,  the  intensity  of  the  inflammation,  ami  the  degree  of 
l)roliferation  of  the  endothelium  of  the  serous  membrane  will 
all  influence  the  cytological  formula,  and  the  significance  of  the 
findings  in  a  given  exudate  or  transudate  will  dejiend  on  a  due 
consideration  of  all  these  factors. 


lit 


THE   CELLS   WHICH   OCCUR    IN    EXUDATES   AND 
TRANSUDATES 

I.  Lymphocytes.— The  preponderance  of  lymphocytes  in 
an  effusion  under  certain  conditions,  especially  tuberculous 
conditions,  was  the  first  fact  about  cytodiagnosis  to  which 
attention  was  directed. 

If  we  inquire  into  the  possible  source  from  which  the  lympho- 
cytes of  an  effusion  are  derived,  we  shall  find  that  they  may 
be  classified  into  angiogenic,  endotheliogenic  and  histiogenic 
lymphocytes,  though  it  is  not  possible  to  decide  between  them 
as  they  are  met  in  an  ordinary  preparation.  The  angiogenic 
Ivmphocvtes  are  those  which  have  wandered,  by  their  intrinsic 
}X)werof  wandering. from  the  blood  stream  or  from  the  lymphatics. 
The  endotheliogenic  Ivmphocvtes  include  those  forms  which 
are  reallv  i»eudo-lvmphocvtes.  the  result  of  degeneration  of 
polynuclear   or  of  endothelial  cells.     The   histiogenic  lympho- 


CYTODIAGNOSIS 


223 


cytes  have  come  from  the  lymphatic  tissues  that  enclose  the 
blood-vessels  supplying  the  serous  membranes.  Signorelli  sup- 
l)oses  that  lymphocytes  may  he  derived  from  proliferation  at 
the  site  of  effusion. 

It  may  be  said  that  lymphocytes  in  an  effusion  are  a  resjionse 
to  a  stimulus  of  low  activity,  the  reaction  on  the  part  of  the 
tissues  in  the  immediate  locality  of  a  disease  which  does  not 
seriously  implicate  the  rest  of  the  organism.  They  are  therefore 
most  frequent  in  effusions  of  a  chronic  nature,  and  if  they  do 
occur  in  the  course  of  acute  disease,  it  is  Iwcause  there  are  repara- 
tive processes  going  on  in  the  damaged  tissues.*  A  weak 
stimulus  spread  over  a  long  space  of  time  constitutes  two 
factors,  which,  existing  as  they  do  in  tulierculous  disease, 
serve  to  explain  the  frequency  with  which  lymphocytotic  effu- 
sions  occur  in  tubercle.t  Where  exceptions  to  this  rule  occur, 
the  explanation  must  be  sought  in  some  sujieradded  acute 
condition,  or  in  greater  toxicity  of  the  micro-organisms,  or  in 
the  presence  of  other  micro-organisms  as  well,  unless  there  lie 
deficient  resistance  on  the  part  of  the  individual. 

The  prejwnderance  of  lymphocytes  is  a  feature  not  only  of 
pleural  tuberculous  effusions  +  (esjiecially  at  the  end  of  the 
second  week),  but  also  of  tubercle  of  the  peritoneum,  jomts. 
tendon  sheaths,  and  any  serous  cavity.  It  may  be  said  that 
if  lymphocytic  effusion  be  of  acute  onset,  it  is  certainly 
tuberculous,  and  that  the  appearance  of  lymphocytosis  after  a 
lX)lynucleosis  indicates  a  favourable  prognosis.  When  jwly- 
nucleosis  gives  place  to  a  lymphocytic  phase  in  the  course  of 
secondary  tubercle  of  the  serous  membranes,  there  wUl  be  an 
absolute  increase  in  the  number  of  cells  per  cubic  millimetre. 

Lymphocytes  are  also  met  with  in  considerable  number  in 
transudates  of  mechanical  origin,§  but  in  nephritic  transudates 
they  number  less  than  20  per  cent.||     According  to  Signorelli, 


*  Signorelli. 

t  This  fact  has  been  verifted  by  many  observers. 


3  lo^v  ..oc  uvv..  ,^ -  ^t  is  only  necessary 

to  nLnVi^n  WidarRavau'tNvolff.  Quincke,  Ehrlich,  Grawitz,  Raubitschek. 
Koster,  Vargas-Suarez,  Stassewicz.  Jacobsohn.  Steinbach,  v.  Ketley  and 
V   Torday.     The  percentage  of  lymphocytes  varies  from  70  to  95- 

t  Attention  may  be  drawn  to  the  fact  that  the  connective  tissue  of 
tuberculous  lesions  is  often  densely  infiltrated  with  histiogenic  lymphocytes. 

§  V.  Ketley  and  v.  Torday,  Bunting. 

11  Stassewciz. 


224 


STUDIES  IN    rUN(  Tl  KE-FI.Uins 


I 


Li. 


IvmphcH  vt«•^  in  excessive  ;um)imt  may  U'  exix-cted  m  effusions 
associated  witli  disease  o{  the  IvmphatJC  system. 

KkKoKS   ok     Dl.ViXOSIS  OF     I.YMi'HDCYTE^ 

I.  /V.«</  imiolhiluil  ,.7/n  ( Plate  i,  li^.  4)  may  assume  tlie 
asjR-ct  of  Ivmpliocytes.*  Jt.  Ihml  pohnndcitr  cells  mav  also 
simulate  them.  .}.  Stinomn  crlls  differ  from  lymphocytes 
because  tlie  former  stain  different  I V  and  their  nuclei  contain 
less  chromatin.  4.  l.ymf^hiHylcs  may  themselves  undergo  ne- 
crotic changes,  when  fat  droplets  and  vacuoUs  apiK'ar. 
3.  /'s,»</(.-/v»i/)/io. y/fs  are  probably  of  various  kind>.  They 
include  Nos.  I  and  2  of  the  alwve  list,  and  also  new-formed 
iinbryonic  connective  tissue  cells  (young  fibroblasts). 

Fseudodymphocytes  are  most  frequent  in  those  tuberculous 
exudates  which  are  associated  with  lymphocytosis  (Koniger). 

The  f«)llowinK  are  distinguishing  features  :  the  size  is  that 
of  a  lymi)hocyte.  the  nucleus  is  relatively  large,  rounil.  rich  m 
chromatin,  and  stains  deeply.  The  cytoplasm  is  moderately 
abundant  and  sometimes  contains  neutrophile  granules.  Often 
they  have  much  resemblance  to  nucleated  red  cells. 

2.  Polynucleosis— The  appearance  of  polynuclear  cells  in 
an  exudate  may  be  looked  on  as  the  expression  of  a  general 
reaction  on  the  part  of  the  individual  against  a  more  severe 
infection.  The  more  virulent  the  infection  the  more  decided 
will  the  polynucleosis  be.  It  is  met  with  in  empyema,  pyopneu- 
mothorax, in  the  initial  stage  of  tubercle,  esjHjcially  when  starting 
in  another  organ .  and  especially  in  tuberculous  pericardial  effusions 
or  when  tuberculous  disease  in  the  lung  is  undergoing  caseation. 

As  a  general  rule,  the  number  of  these  cells  diminishes  as  the 
case  progresses  towards  recovery,  and  lymphocytosis  takes  its 
place.  On  the  other  hand,  if  {xjlynucleosis  takes  the  place  of  a 
lymphocytosis  in  a  pleural  effusion  in  a  cardiac  case,  one  should 
susi^ect  the  development  of  an  infarct.  The  state  of  preservation 
of  these  cells  occasionally  gives  a  clue  to  the  nature  of  the  case. 

Ekkors  of  Diagnosis  of  Polynicle.\r  Cells.— They 
may  be  simulated  by  degeucraie  cells  of  other  kinds,  owing 
to  fragmentation  of  the  nucleus.      Careful  focussing  will  assist 

in  distinguishing  them. 

•  Patflla. 


CYTOl>IA(iNOSIS 


22$ 


Pseudo-lymphocvUs  have  In-en  n-fcrrod  to  (p.  224). 

PolynticUar  cells  may  thtinstlves  unilergo  JegeHeralive 
changes.  Tht-ro  is  then  fragmentation  of  the  nucleus,  disapjiear- 
ance  of  granules,  swelling  of  the  cell-lKKly  ("  hydroi*  ").  loss  of 
staining  iM)wer  of  the  nucleus,  and  even  bursting  of  the  cells. 
Such  <legenerate  cells  may  U-  found  as  cell-inclusions  in  endo- 
.helial  cells.  Shrinkage  of  ix)lynuclear  cells,  with  fragmentation 
of  the  nucleus,  occurs  in  tulx-rculous  pleurisy  secon<lary  to  pul- 
monary disease. 

3.  Endothelial  Cells.- (Plate  i,  tigs.  2  and  4) -The 
presence  of  a  large  numlxr  of  endothelial  cells  in  a  fluid  is  suffi- 
cient to  enable  one  to  exclude  an  ordinary  inflammatory  process. 
They  are  es|H?ciallv  characteristic  of  transudations  from  back- 
pressure and  may  then  form  (»<)  jK-r  cent,  of  the  total  cells.  As  one 
would  e.\jH>ct,  they  are  derived  from  proliferation  of  the  endothe- 
lium of  the  serous  membrane,  the  proliferated  cells l)ecoming  shed. 
They  are  more  likely  to  apj)ear  as  a  result  of  rei)eated  tapping  of 
a  serous  cavity,  presuming  that  the  effusion  is  purely  of  mechani- 
cal origin.  In  cases  of  inflammatory  effusion  there  will  f)e  no 
change  in  the  variety  of  the  cellular  elements,  a  fact  which  is 
of  great  imjwrtance  in  differentiatmg  tloubtful  cases  of  tulwrcle, 

for  instance. 

A  large  number  of  endothelial  cells  in  an  effusion  of  traumatic 
origin  may  lie  looked  on  as  a  good  prognostic  sign,  esj^cially  if 
any  jwlynuclear  cells  that  may  co-exist  are  in  a  good  state  of 
preservation.  It  must  be  Iwrne  in  mind  that  some  cases  of 
Itiherck  show  even  as  much  as  ()0  })er  cent,  of  endothelial  cells 
in  the  early  stages  of  an  effusion,  while  they  disaptK>ar  later  on. 

The  presence  of  endothelial  cells  in  a  ^xiritoneal  fluid  in  cases 
of  simple  ovarian  tumour  has  been  noted  by  some  observers. 


Errors  in  Di.\gnosis  of  Endothelial  Cells. 

1.  Leucocytes.— U  endothelial  cells,  in  virtue  of  their  phago- 
cytic lowers,  have  taken  up  leucocytes,  they  may  come  to  be 
mistaken  for  the  latter. 

2.  Carcinoma  Cells.— It  has  often  l)een  said  that  one  cannot 
distinguish  between  these  two,*  but  so  definite  a  negation  must 

•  Lately,  Sawyer.  1908. 

X5 


226 


I  r 


STUniES  IN    I'UNCTURE-FLUIDS 
The  characters  of  endothehal  cells  and  of  carcinoma 


be  disputed.     T 

cells  are  shown  on  Plate  i,  tigs.  2  ana  4,  anc.  r.a.c  ..  "b-  -.•  — 
useof  colour  serving  to  accentuate  the  features.    We  may  say  hat 
(.0  the  cdothehal  cell  has  usually  a  very  large  cell-body  with  a 
regular  oval  nucleus  (Plate  i,  tig.  2).  which  stains  but  feebly  w,h 
Tenner     While  the  cell-body  may  show  %-acuolation.  it  has  usua  ly 
a  perfectly  uniform  structure.     (I»  The  cells  have  all  a  similar 
appearance.      Contrasting  carcinoma  cells,   we   find   that   here 
there   are    hardly   two    alike,    (i)    the  cytoplasm   never  stains 
uniformly,  and  is  (ii)  often  vacuolate  and  contains  fat  granules 
and  cell-inclusions  C  bird's-eye-l.ke  "  structures-Erben   ;     c) 
the    nucleus   under    favourable  circumstances    stains    deeply, 
and    shows    mitotic     figures,   often   of     heterotype    charac  er, 
besides     frequently     containing     several      nucleoli     (Plate  2 
fig    3)  •    (d)   the  adhesion  of  many  cells  in  a  bud-l.ke  fashion 
is    frequent.     Some    of    the    cells    are    multinucleate^     (.)  It 
is    hardly   fair   to   cite,   in  exemplification   of    the   ability    to 
diagnose    cancer-cells,    the    appearance    of     the    phenomenon 
depicted    m  Plate   2.  iig.    i.   for  an    opportunity  of     "s  kind 
mist   be   rare.     It  is,  however,  conclusive^     The   fluid  in   tins 
particular  case    was  turbid,   and   the  turbidity  was  found    o 
le   due    to  particles  formed  of   clusters  of    cells   of   i>erfectly 
distinctive  character  even  in  the  unstained  preparation.      The 
drawing  is  prepared  from  a  paraffin  section  made  from  a  mass  of 
Te  deposit  that  was  dehydrated  and  embedded.     The  columnar 
shape  of  the  cells,  which  are  rather  degenerate,  and  the  central 
stroma,  are  shown.     It  is  of  course  not  certain  that  this  was  from  a 
peritoneal  fluid  rather  than  from  an  ovarian  cyst,  and,  unfortu- 
nately, neither  operation  nor  post-mortem  examination  was  l^r- 
mitted.    (/)  The  usual  type  of  carcinomatosis  consists  of  a  diffuse 
growth  scattered  all  over  the  peritoneum  and  sheddmg.tsce  Is  into 
the  fluid  that  its  presence  has  excited.     These  cells  are  often  de- 
generate, and  cannot  be  distinguished  from  similar  y  degenerate 
endothelial  cells.     A  comparison  of  all  the  cells  of  the  effusion 
and  a  search   for  some  better-preserved  types  may  reveal  the 
nature  of  the  case.     The  difliculties  are  of  course  insuperable 
where  there  is  much  endothelial  hyperplasia  as  well  as  the  car- 
-momatosis.     Solid  fragments  of  tissue  would  settle  the  diag- 
nosis  but  even  in  their  absence  the  diagnosis  is  not  as  hopeless 
r  ome  would  have  us  believe.    The  drawings  referred  to  have 


CYTODIAGNOSIS 


!27 


been  made  from  s{iecimens  obtained  in  the  Leeds  General  In- 
firmary, and  are  from  cases  verified  post  mortem,  so  that  there 
can  be  no  plea  that  carcinoma  cells  were  not  present  in,  say, 
Plate  2,  fig.  3.  There  were  enormous  numbers  of  these  cells,  and 
there  was  also  pleural  carcinomatosis  absolutely  widespread. 

3.  Large  Mononuclear  Ce//s.— These  will  be  considered  under 
the  next  heading. 

4.  Large  Mononuclear  Cells.— These  cells  are  best  distin- 
guished in  unstained  preparations.  Changes  in  the  osmotic 
conditions  of  the  fluid  after  tapping  tend  to  alter  their  characters 
greatly,  so  that  early  examination  becomes  particularly  im- 
portant. They  are  depicted  in  f^g.  4  of  Plate  i.  They  i^ssess 
phagocytic  properties,  and  are  apparently  derived  sometimes 
from  connective  tissue  cells,  sometimes  from  endothelial  cells,  and 
sometimes  from  the  blood-stream,  while,  according  to  Marchand, 
they  may  come  from  the  perivascular  lymphatic  tissue  (leucocy- 
toid  cells).  The  phagocytic  cells  are  very  large  in  size,  and 
often  have  included  fragments  of  degenerate  cells.  If  they  are 
increasing  in  num  "  they  indicate  a  favourable  prognosis,  while 
if  they  are  absent  aom  the  deposit  in  an  inflammatory  effusion, 
and  bacteria  appear,  their  absenre  indicates  approaching  suppura- 
tion. In  early  tuberculous  effusions  they  may  number  i  per  cent, 
of  the  total  cells  (Bunting).  They  have  been  met  with  in  the 
pleural  effusion  associated  with  enteric  fever. 

5.  Eosinophile  Cells.— Two  classes  of  eosinophilia  may  be 
described— a  relative  and  an  absolute  eosinophilia.  The  latter 
exists  when  the  -  ells  number  from  10  up  to  74  per  cent,  of  the 
total  count.  The  significance  of  so  high  a  count  is  unknown, 
though  It  has  been  described  as  occurring  in  cases  gf  acute  rheu- 
matism, in  nephritis,  and  in  convalescent  cases  of  tubercle. 
Burnet  regards  the  phenomenon  as  indicating  diminution  of  the 
virulence  of  the  organism,  while  Bibergeil  ascribed  it  to  chemo- 
tactic  influence  of  broken-down  endothelial  cells. 

There  is  generally  eosmophilia  of  the  blood  at  the  same  time, 
though  this  is  not  met  with  in  infective  cases,  with  the  exception 
of  syphilitic  cases,  as  Widal  and  Ravaut  record. 

Eosinophilia  has  been  described  in  several  cases  of  carcinoma, 
thus,  by  Erben,  by  v.  Starck,  by  Kroniger.     When  it  appears  in 


228  STUDIES  IN    PUNCTURE-FLUIDS 

an  effusion  which  developed  since  a  growth  was  noted  in  another 
Tart  of  the  body,  U  may  I.  assumed  that  metastases  has  taken 
place. 

In  V   Starcks  case  there  were  also  enormous  cells  which  f  *"«;!  I^^^^^'^^ 

rh  v'-icuolated  and  contained  peripherally  situated  nuclei.     He 
were  much  vacuolated  an.  J  ^^^^^^^^  ^^^^^^^  _^  ^^,^^^  ^,,,^ 

;:;:atertap;rr  up  tTa  certain  point,  after  wh.ch  .t  .ecame  „«hter  .n 
colour. 

6  Mast  Cells.-These  may  often  be  seen,  especially  if  the 
fluid'  be  examined  rapidly.  They  occur  in  chrome  effusions 
chiefly,  and  are  pathological,  since  they  are  never  found  m  the 
normal  fluid  bathing  the  serous  membranes. 

7  Red  Blood  Cens.-Apart  from  accidental  contamination 
importance  has  always  been  attached  to  the  presence  of  blood 
n  an  effusion  as  mdkatmg  ehher  tubercle,  carcmoma,  or  rena 
diseL  It  may  occur,  however,  in  metapneumonic  empyema  * 
andTn  rheumatl  cases.f  A  large  amount  of  blood  is  met  with 
in  those  rare  cases,  of  course,  where  a  thoracic  aneurism  is 
gradually  leaking  into  the  pleural  cavlt^^  In  such  a  case  the 
utmost  importance  will  be  attached  to  the  finding. 

8   Carcinoma  or  Sarcoma  Cells   (Plate  2,  fig.  3)-The 
apiL^nce  oMhese  cells  in  an  exudate  may  be  looked  on  as  of 
dEostic  value  to  an  extent  which  does  not  exist  m  the  diag- 
nS  carcinoma  of  any  solid  organ.     The  presence  of  carcinon.a 
cells  in  the  sputum,  in  the  stomach  contents,  or  in  the  f^es  or 
urL  must  be'looked  upon  as  mamly  mythical  as  it  is  out  of  the 
question  to  distinguish  between  malignant  cells  and  the  endo- 
Tlial  or  epithelial  cells  of   the  passages.     We  can  only  hope  to 
diinose  the  condition  from  the  presence  of  cell-masses      But  m 
srous  cavities  freer  conditions  obtain,  and  although  fragmen  s 
of  tbsue  may  occur,  the  individual  cells  are  much  more  capa^,le 
o    accurate  study.     The  chief  features  of  diagnosis  have  been 
gone  mto  fully  on  page  2.(..  and  need  not  be  agam  described. 

Quincke  described  a  glycogen  reaction  m  carcmoma  cells 
granules  visible  on  staining  with  iodme-gum  being  met    with 

.  Raubitschek;    also  a 'recent  case  in  the  Leeds  General  Innrmary. 

t  l-:arl. 


CYTODIAGNOSIS 


229 


in  such  cells  ;  but  little  importance  can  be  attached  to  this  from 
the  diagnostic  point  of  view,  in  the  same  way  as  the  glycogen 
reaction  of  pus  cells  so  often  proves  misleading. 

Errors  in  DiAGNOSis.-{a)  Endothelial  cells,  when  en- 
tangled in  fibrin,  may  simulate  carcinoma  cells,  (b)  Vacuolated 
cells  may  occur  in  ascites  connected  simply  with  an  ovarian 
cyst  or  in  benign  tumours  of  the  ovary.  The  most  serious 
difficulty,  however,  is  that  there  may  be  no  free  tumour  cells  at 
all  in  the  exudate,  or  that  those  which  were  shed  have  become 
dissolved.  Grenet  and  Vitry,  too,  describe  two  cases  in  which 
the  peritoneal  fluid  in  a  case  of  carcinomatosis  contained  only 
lymphocytes,  large  mononuclear  cells,  and  red  corpuscles. 


Certain  Special  Fluids. 

Hydrocele  FLViD.-Flakes  of  endothelial  cells  or  isolated 
cells  are  met  with  in  large  numbers  in  simple  hydrocele,  and 
sometimes  they  are  abundant  in  chronic  hydrocele.  As  a  rule, 
the  other  cellular  elements  follow  the  familiar  tyi^es.  Lympho- 
cytes preponderate  in  tuberculous  hydrocele,  or  in  any  chronic 
inflammatory  process.  Polynucleosis,  on  the  other  hand,  is 
generally  (not  always)  associated  with  acute  mflammation— 
usually  gonococcal.  The  irritation  produced  by  tapping,  and 
especially  by  injecting  such  remedies  as  iodine,  will  result  m  the 
appearance  of  endothelial  cells  and  lymphocytes  (Julhard). 

Joint  Fluids.— In  the  effusions  into  joints  resultmg  from 
various  causes  the  various  tyi^s  of  cell-elements  give  similar 
indications  to  those  of  other  serous  membranes.     Thus,  polynu- 
clear  cells  predominate  in  gonorrhceal  or  acute  suppurative  cases, 
though,  if  there  be  no  pyrexia,  there  may  be  only  lymphocytes 
present     The  same  polynucleosis  occurs  in  acute  rheumatism, 
and  in  irritation  after  tapping.     Lymphocytes  indicate  a  chronic 
affection,   much  less   frequently   tuberculous   than   with  other 
serous   membranes,   and   a  small    proportion    of    endothehal 
cells  is  frequently  met  with.     Rice-bodies  are  associated  with 
lymphocytosis.     Red  cells  are  likely  to  be  found  in  fair  number 
in  tuberculosis  of  joints.     Tabetic  joint  effusions  contam  very 
few  cells.and  these  are  mostly  lymphocytes  and  large  mononuclear 

cells. 

Cerebrospinal  FLUio.-On  reviewing  the  enormous  accumu- 


230 


STUDI?:S   IN   PUNCTUUE-KLUIDS 


1. 


lation  of  literature  of  the  cytology  of  cerebrospinal  fluid  alone, 
we  strike  upon  one  great  fact,  namely,  that  in  functional  disease 
the  lumbar  j)uncture  will  show  few.  if  any.  cellular  elements  at 
all.  while  if  there  be  organic  disease  of  the  brain  or  spinal  cord, 
we  may  exjiect  to  find  a  considerable  number  of  cellular  elements, 
a  differential  count  of  which  will  assist  in  the  diagnosis  of  details 
with  similar  limitations  to  those  that  obtain  in  the  case  of  pleural 
and  jx-ritoneal  fluids.  Probably  in  this  kind  of  fluid  the  real 
significance  of  lymphocytosis  oi  polynucleosis,  or  of  a  mixed 
type,  is  similar  to  that  which  obtains  for  pleural  and  jxiritoneal 
fluids,  namely,  that  it  is  not  so  much  a  question  of  tubercle 
or  other  organisms,  as  that  in  the  one  case  the  inflammatory 
change  is  of  a  much  less  active  kind,  demanding  fewer  phagocytes. 

The  varieties  of  cytological  formula  which  may  be  met  with 
may  be  groujied  under  the  following  headings  : 

{a)  Absence  of  cellular  elements,  or,  fewer  cells  than  two  per  cubic 
millimetre.  This  is  the  n.'.rmal  condition,  as  shown  by  many 
investigators  (Schwarz,  Bronstcin,  V'erzeanu.Devaux,  Schlesinger, 
and  others).  Cells  are  absent  in  such  purely  mental  diseases 
as  mania,  paranoia,  melancholia,  imbecility,  acute  alcoholism, 
delirium,  senile  dementia  (Merzbacher). 

If  there  be  no  cellular  elements  present,  or  if  their  number  be 
not  greater  than  two  per  cubic  mm.,  this  is  sufficient  to  exclude 
any  meningeal  inflammation,  syphilitic  meningitis,  and  such 
diseases  as  tabes,  superficial  gummata,  tumours,  hypertrophic 
pachymeningitis.  A  similar  condition  is  met  with  in  the  cerebro- 
spinal fluid  in  cases  of  herpes. 

(b)  Lymphocytosis. — This  term  denotes  either  a  relative  excess 
of  lymphocytes  over  the  other  cell-elements  or  it  means  that 
lymphocytes  constitute  the  only  cells  jiresent. 

Lymphocytosis  occurs,  to  a  moderate  extent  only,  in  some 
cases  of  dementia  paralytica,  of  chronic  alcoholic  paralysis  and 
of  disseminated  sclerosis,  while  it  occasionally  occurs  in  perfectly 
normal  fluids  (Schwarz  and  Bronstein).  Sj^aking  broadly, 
lymphocytosis  occurs  in  any  meningeal  inflammation  that  is  of 
chronic  nature.  It  is  therefore  met  with  in  tuberculous  meningitis 
(esjiecially  in  children),  in  syphilitic  meningitis,  whether  con- 
genital *  or  acquired.t     It  has  Ijeen  found  in  cases  of  herpes, 

*  Kretschmer. 

t   Raubitschek,  Devaux,  Donath. 


CYTODIAGNOSIS 


231 


of  mumps,*  and  of  tabes,  as  well  as  in  epileptics  f  (showing 
that  epilejjsy  is  not  purely  a  "  functional  "  disease).  It  has 
been  observed  that  when  lymphocytosis  occurs  in  a  syphilitic 
case  mercury  causes  the  cells  to  disappear. 

The  view  has  been  expressed  J  that  lymphocytosis  is  not 
characteristic  of  syphilitic  nervous  disease,  but  that  it  is  only 
present  if  the  meninges  are  involved. 

There  are  one  or  two  additional  points  to  note  about  this  type 
of  cell-predominance  :  (i)  its  development  during  the  course  of 
a  case  indicates  improvement.  (2)  If  polynucleosis  were  present 
before,  the  supervention  of  lymphocytosis  may  be  regarded  as  a 
favourable  sign.  (3)  It  is  not  present  during  the  initial  stages  of 
tuberculous  meningitis.  On  the  other  hand,  in  the  later  stages 
of  this  disease  one  may  e.\i)ect  to  find  as  many  as  10,000  cells 
per  cubic  millimetre. 

(c)  Polynucleosis. — This  generally  signifies  an  acute  suppura- 
tive meningitis,  or,  at  any  rate,  acute  meningeal  disease.§  It 
may  develop  in  the  initial  stages  of  tuberculous  meningitis,  and 
is  otten  continuously  present  in  the  tuberculous  meningitis  of 
adults.  It  is  met  with  in  cases  of  commencing  poliomyelitis, 
and  in  cases  of  herpes.  In  cerebrospinal  fever  there  is  an  excess 
of  polynuclear  cells  at  the  outset  of  the  disease,  and  at  each  exacer- 
bation of  the  fever.  Sawyer  gives  :  polynuclear  cells  84  per  cent., 
lymphocytes  15-6  per  cent.,  degenerate  cells  04  per  cent.  It 
may  occur  during  the  congestive  attacks  of  hemiplegia. 

It  is  important  to  note  the  state  of  the  preservation  of  these 
cells,  for  if  transient  aseptic  disease,  such  as  during  syphilitic 
nervous  disease,  is  present,  the  cells  will  be  found  particularly 
well  preserved. 

The  number  of  cells  per  cubic  millimetre  in  a  case  of  suppura- 
tive meningitis  may  reach  100,000,  of  which  53  or  more  per  cent, 
will  be  polynuclears.  The  number  diminishes  as  the  case  pro- 
gresses towards  recovery.  In  a  case  of  cerebral  abscess  ||  there 
were  97  jier  cent,  of  polynuclear,  24  per  cent,  of  lymphocytes, 
04  per  cent,  of  degenerate  cells,  and  02  per  cent,  of  endothelial 
cells.  (One  would  dispute,  from  one's  own  experience,  whether 
endothelial  cells  can  be  identified  in  cerebrospinal  fluid.) 

(d)  Other  Cellular  Eletnenls. — Blood  may  be  present  in  cere- 

*  Raubitschek.  f  Merzbacher.  X  Funke. 

$  V'erzeanu,  Devaux,  Donath.  jj  Sawyer. 


232 


STUDIES  IN   rUNCTURE-FLUIDS 


brospinal  fluid,  apart  from  accidental  contamination,  in  cases  of 
intracranial  h,-emorrhage  where  the  blood  has  made  its  way  into 
the  meningeal  cavities.  In  a  case  of  this  kind,  Sabrazes  and 
Muratet  found  round  or  oval  px)lyhedral  isolated  cells  or  masses  of 
such  cells,  containing  fragments  of  red  corpuscles,  or  haematoidin 
granules.  These  they  regarded  as  "  macrophages,"  derived 
from  the  endothelium  of  the  subarachnoid  spaces.  Such  cells 
may  contain  fatty  granules,  fragments  of  myelin,  and  pigment. 

The  presence  of  large  monontidear  cells  with  basophile  proto- 
plasm, and  eccentric  nucleus,  has  l)een  described  as  occurring  in 
tubercular  meningitis,  but  they  also  occur  in  tabes  and  cerebro- 
spinal syi)hilis. 

Tumour  cells  have  been  described  as  occurring  in  cerebrospinal 
fluid  by  Sahli. 

Degenerate  cells  in  cerebrospinal  fluid  have  been  explained 
as  due  to  decomposition  having  set  in  ;  but  it  is  satisfactory  to 
learn  that  Pappenheim  has  offered  the  view  that  the  degenerate 
character  is  evidence  of  pathological  processes,  and  that  it  is  the 
result  of  a  toxic  action  exerted  by  the  diseased  cerebrospinal  fluid 
on  the  ]X)lynuclear  cells.  This  type  of  cell  occurs  most  frequently 
in  paralytics,  and  the  proof  adduced  is  that  warming  the  fluid  to 
56°  C.  causes  it  to  cease  to  have  any  deleterious  action.* 

The  presence  of  organisms  such  as  spirochaetes  or  trypano- 
somes  does  not  come  within  the  scope  of  this  work. 

The  rate  of  flow  of  the  fluid  from  a  lumbar  puncture  has  been 
laid  undue  stress  on  by  some  authors,  but  to  adduce  arguments 
for  believing  so  is  out  of  place  here. 

Ovarian  Cysts. — The  cellular  elements  in  these  cases  are 
almost  pathognomonic,  and  are  so  well  known  as  hardly  to  call 
for  more  than  mere  mention.  Columnar  epithelial  cells,  ciliated 
epithelial  cells,  and  squamous  epithelial  cells  may  be  met  with, 
according  to  the  character  of  the  growth.  Cells  with  fatty  granules 

•  Ont'  may  emphasi.se  this  idea  of  Pappenheim 's  by  caHing  attention  to 
the  fact  that  degenerate  appearances  which  are  observed  are  only  too 
readily  ascribed  to  imperfect  technique  :  thus,  a  liver  which  becomes  almost 
fluid  on  removal  from  the  body  is  often  regarded  as  an  example  of  early 
post-mortem  decomposition.  So  with  the  suprarenal  gland.  As  a  matter 
of  fact,  most  livers  and  suprarenals  do  not  break  down  readily,  even  if  the 
necropsy  is  delayed  48  hours.  The  explanation  of  the  undue  friability 
must  therefore  be  sought,  as  there  must  be  a  reason  for  such  changes  apart 
from  "  accident." 


CYTODIAGNOSIS 


235 


are  also  characteristic,  especially  in  multilocular  cysts.  Colloid 
masses  may  appear  in  the  fluid  in  cases  of  colloid  carcinomata. 
The  presence  of  cholesterin  crystals  is  a  frequent  feature  in 
ovarian  tumours,  and  has  even  been  met  with  in  a  simple  par- 
ovarian cyst  (in  this  Infirmary),  though  such  cysts  have  usually 
perfectly  clear  watery  contents. 

Special  Findings  in  the  Deposit  of  Puncture-Fluids. 
— Hamatoidin  crystals  occur  in  empyema,  subchronic  abscess, 
pulmonary  abscess,  and  esjwcially  in  old  suppurating  hydatid 
cysts.     They  indicate  antecedent  haemorrhage. 

Food  particles  may  be  found  in  the  p)eritoneal  fluid  after 
perforation  in  the  course  of  the  alimentary  canal.  Tumour 
fragments  may  be  met  with.  Myelin  bodies,  com})osed  of  prota- 
gon,  are  referred  to  by  Sahli  as  being  abundant  in  tumour  of  the 
lung  which  has  invaded  the  pleura.  Fatty  acid  crystals  occur  in 
putrid  collections  of  pus.  Triple  phosphate  crystals,  calcium, 
carbonate,  and  phosphates  may  be  seen  in  i)urulent  collections. 
Hydatid  hooklets  or  scolices  may  be  found,  and  renal  casts  will 
occur  in  the  corresponding  cysts. 

Spontaneous  coagulation  of  a  fluid  is  an  indication  that  fibrin 
ferment  was  present. 

Scheme  for  Differential  Diagnosis  in  Special  Cases. 
— ^The  following  scheme  has  been  devised  from  the  data  supplied 
by  Koniger,  as  it  may  be  found  useful : 


'  Ljmphocytosis 


c 
o 


appearing 
in  the 
course  of 
in  f  1am- 
matory 
disease. 


Without  associated  j' tubercle 
endothelial      des— | 
quamation  \  syphilis 


Much  the  com- 
moner. See  if 
the  "formula" 
alters  after 
repeated  tap- 
ping, 
endothelial    desquamation 


Ejirly  stages   of    ill. 
ness,  no  endothelial* 
cells  present. 


pure  poly- 
nucleosis! 


if  cells  de- 
generate 


With    associated 

=:  sarcoma. 
Indicates  diminished   virulence   of  bacterial 
infection. 

if  cells  well-preserved  =  sterile  effusion, 
'cells  shrunken  =  tubercular 
pleurisy,  secondary  to  adja- 
cent lesion, 
cell    body    swollen  =  acute 
infective  pleurisy, 
polynucleosis  with  lymphocytes  =  pleurisy  following 
tubercle  of  the  lungs ;    if  fatty   granules  suspect 
V  caseation. 
Abd      ■     1  i^^  pyrexia  present  =  tubercle. 

omina  I  /where   previous  puncture  was  performed  — 

«*"^'°"'^  J   cirrhosis  of  liver. 

ceU  type  I  [ 


ofmixed-VfnopyrexUpresentJ^^^^  ,^^  cell-formuU   cannot   be    due    to 

previous  puncture  < 


tubercle. 


234 


STLDIKS  IN    PUNCTURE-FLUIDS 


I 


The  Chemistry  of  the  Cell-elements   present.  —  This 

subject  docs  not  come  under  cytodiagnosis,  but  reference  is  made 
to  it  in  order  to  draw  attention  to  the  fact  that  upon  the  com- 
position of  the  cells  present  in  an  effusion  the  chemical  characters 
will  to  a  certain  extent  dejHjnd.  The  degeneration  of  the  cells 
will  naturally  lead  to  the  substances  of  which  they  were  comjwsed 
appearing  free  in  the  Huid.  The  exact  substances  present  will 
be  found  on  reference  to  the  appropriate  headings  in  the  preceding 
sections,  but  es|)ecial  attention  may  l)e  drawn  to  the  facts  made 
out  by  Miiller  and  Jochmann,  which  go  to  show  that  the  granules 
in  i)olynuclear  cells,  not  to  mention  the  eosinophile  granules,  are 
jirobably  of  the  nature  of  zymogen  granules,  and  that  they  are 
intimately  connected  with  the  proteolytic  ferment  which  exists 
in  leucocytes.  In  this  manner  it  will  be  obvious  that  the  granu- 
lar appearance  of  a  })olynuclear  cell  must  be  placed  on  a  par  with 
the  appearance  of  gland  cells  (such  as  salivary  gland  cells)  at 
different  stages  in  their  activity. 


EXPLANATION    OF  THE    PLATES 

Plate  i 

Fig.  I.  The  bulk  of  the  cells  in  this  ligure  are  lymphocytes, 
many  of  them  having  a  granular  appearance.  In  the  middle  is  a  large 
mononucleate  cell,  also  very  granular,  and  of  endothelial  origin.  Just 
below  it  wdl  be  seen  a  large  mononuclear  cell  of  angiogenic  origin.  The 
small  cluster  of  lymphocytes  will  be  readily  distinguished  (in  an  actual 
specimen)  from  the  clusters  of  carcinoma  or  sarcoma  cells  depicted  in 
Plate  2.  lig.  2.     Eyepiece  2,  objective  {  in. 

Fig.  2.  This  shows  the  typical  endothelial  plaques  met  with  in  the 
deposit  in  cases  of  back-pressure.  A  few  lymphocytes  are  shown,  with 
which  the  size  of  the  endothelial  cells  can  be  compiared.  A  large  mononu- 
clear cell  (angiogenic),  a  cluster  of  dead  cells  and  a  binucleate  cell  will  also 
be  noticed.     Oil-immersion  lens. 

Fig.  3.  Cells  from  a  case  of  polyorrhomenitis.  These  are  mainly 
degenerate  cells,  some  are  vacuolated,  though  finely  granular  matter  can 
be  seen  in  the  vacuoles.  The  nuclei  in  the  dff  eaerate  cells  are  devoid  of 
chromatin.  \  group  of  pseudo-lymphocytes  is  shown  on  the  right,  as 
well  as  true  lymphocytes.     Eyepiece  2,  objective  J  inch. 

Fig.  4.  Dililerent  types  of  cells,  (a)  degenerated  endothelial  cell  from  a 
case  of  cirrhosis  of  the  liver  ;  (fc)  large  mononuclear  cell,  with  pale  cell-body 
and  pale  nucleus  ;  (c)  cell  with  "  mast  "  granules,  from  a  case  of  tubercular 
peritonitis ;  (d)  large  ^^-generated  endothelial  cell — chronic  pleural  etlusion  ; 
(f )  enormously  swollen  endothelial  tell  from  the  same  case  ;  (/)  lym- 
phocytes.    All  the  cells  are  drawn  to  scale.     Oil-immersion  lens. 

Fig.  5.  Degenerated  cells  of  difierent  types :  a,  b,  c,  and  d  ase  endothelial 


/  " 


■J 
'J 


CJ 


/■■/  / 


d« 


f         \ 


/  1^ 


ft  ^ 

• 


c 


o   ^ 


rV 


//./  -. 


//'/  •/ 


rt 


•       9 

If      ^  d 


/ 


/ 


/■/// 


«♦ 


"'    ,*    ^ 


•f     " 


O      i 


S-v-    / 


'• 


/    o       -    •    \ 


r:/ 


*l 


/ 

if. 


/  ^/'^ 


0 

i 


/  /'/ 


/ 


/ 


i 


1- 


pp. 


CYTODIAGNOSIS 


^35 


cells  ;  c  shows  nucleus,  with  nucleolus,  granules,  and  degenerating  cyto- 
plasm ;  d  is  astruct-ivless  mass;  e  large  mononuclear  cell.  The  bacilli 
are  Bacillus  lympka         n  (Hamburger).     Oil-immersion  lens. 


Plate  2 

Fig.  I.  Fragments  of  tissue  irom  the  peritoneal  fluid  in  which  there 
was  dissemination  of  carcinoma.  Columnar  cells  are  seen  on  a  t>asement 
membrane.  There  art  indications  of  structure  within  the  globules  of 
tissue.  The  spherical  appearance  was  well  seen  in  the  fresh  specimen. 
Eyepiece  2,  objective  J  inch. 

Fig.  2.  Cells  from  a  case  of  sarcomatosis  of  the  peritoneum.  (a) 
Sarcoma  cell  whose  nucleus  has  two  nucleoli,  and  large  granules  are  seen 
in  the  cytoplasm  ;  (6)  typical  clusters  of  cells  with  deeply  staining  nuclei. 
There  were  extremely  large  number,  of  these  clusters  present  in  each  lilm. 
(0  large  mononuclear  cells  ;  (rf)  lymphocytes  (the  relative  sizes  of  the  cells 
are  readily  seen  from  these)  ;  (e)  swollen  degenerate  cell  ;  (/)  a  few  sarcoma 
cells  in  juxtaposition,  showing  deeply  staining  nuclei,  and  deeply  staining 
cytoplasm.     Eyepiece  2.  objective  I  inch. 

Fig.  3.  Endothelial  and  carcinoma  cells,  (a)  Red  cells;  (b)  lympho- 
cytes •  (c)  endothelial  cells  ;  (d)  swollen  cells  containing  several  nuclei 
and  nucleoli;  (e)  carcinoma  cell  showing  mitotic  figure;  (/)  excessively 
swollen  endothelial  cell.     Oil-immersion  lens. 

Fig.  4.  Cells  from  peritoneal  carcinomatosis.  Shows  large  vacuolated 
cells,  some  large  multinucleate  cells,  some  binucleate  cells  and  large  deeply 
staining  mononuclear  cells.     Oil-immersion  lens. 


i 


SECTION    VI 

SPECIAL   CASES 

Thk  application  of  the  facts  recorded  in  previous  pages  and  of 
the'vanou.  methods  of  diagnosis  which  have  been  advocated 
is  lH>st  illustrated  by  the  relation  of  certain  special  cases  which 
have  been  examined.  Ihe  various  observations  made  on  the 
specimens  of  fluid  received  for  examination  are  here  recorded, 
and  the  deductions  which  have  been  made  as  to  the  nature 
of  the  fluid  are  introduced.  The  post-mortem  diagnosis 
subsequently  obtained  is  introduced,  and  affords  an  opportunity 
of  commenting  on  the  diagnosis  made  in  those  cases  where 
one's  conclusions   proved   to   be   at   variance    with   the  actual 

^'^The  greatest  difficulty  is  undoubtedly  attached  to  the  diag- 
nosis of  the  effusions  in  either  chest  or  abdomen,  especially  in 
medical  cases,  and  it  becomes  more  useful  to  refer  solely  to  these 

two  kinds  of  fluid.  , 

The  cases  are  groui)ed  therefore  into  (a)  pleural,  and  (b) 
peritoneal,  but  no  other  order  is  observed.  Only  those  which 
presented  features  of  particular  interest  or  of  difficulty  are  con- 
sidered in  this  section. 


(A)  PLEURAL   FLUIDS 

I  G  aged  40  —The  fluid  was  straw-coloured,  with  blood- 
staining' of  the  deposit.  The  specific  gravity  was  1012.  There 
were  no  endothelial  cells  in  the  deix)s.t,  which  contamed  a  few 
lymphocytes  and  some  red  cells.  ,    . ,     •  j  » 

The  chemical  examination  showed  an  abundance  of  chlorides 
(8  gm.  per  litre),  and  a  very  small  amount  of  albumen  (o'S  per 
cent.).     There  was  no  glycoproteid  present. 

2^6 


SPECIAL  CASES 


237 


The  concentration  of  electrolyte'^  was  0-2460,  of  which 
0-0424  consUted  of    achlorides.     The    ratio  achloride/chloride 

was  0-21. 

The  post-mortem  examination  showed  cardiac  incompetence 
due  to  valvular  disease  (aortic  and  mitral).  There  was  also 
ascites,  cirrhosis  of  the  liver,  infarcts  in  the  lung,  spleen,  and 

kidney. 

The  findings  in  the  pleural  fluid  jwint  to  a  passive 
accumulation  of  fluid  (transudation),  partly  because  there  was 
an  increase  in  the  chloride-content,  and  partly  on  account 
of  the  arhloride/ chloride  ratio.  All  the  facts  made  out  fall  in 
line  with  the  diagnostic   indications  which  were   mentioned   in 

Section  IV. 

II.  Richard  H.,  aged  26.— The  straw-coloured  fluid  had  a 
siJecific  gravity  of  1032,  and  showed  a  considerable  deposit, 
mainly  of  lymphocytes. 

The  chemical  examination  showed  a  maximal  quantity  of 
albumen,  and  a  considerable  quantity  of  chlorides  (7-25  iw  cent.). 
The  presence  of  other  substances  was  not  investigated. 

The  electroconductivity  examination  showed  the  amount 
of  total  electrolytes  to  be  0-2319,  rnd  the  achlorides  were  as 
much  as  -1533  (total  concentration  in  terms  of  Xa.COj).  The 
achloride  chloride  ratio  was  therefore  alxjve  unity,  2-95. 

On  the  strength  of  these  facts,  high  albumen-content,  high 
"  salt  "  ratio,  and  the  cytological  characters,  the  diagnosis  of 
inflammatory  effusion  of  tul^erculous  origin  was  made. 

III.  Alfred  B.,  aged  15.— A  green,  fluorescent  fluid,  having 
a  specific  gravity  of  1021,  contained  2  per  cent,  albumen. 

The  concentration  of  the  chlorides  was  0043  gram-mol.,  while 
the  total  concentration  of  the  electrolytes  amounted  to  0113. 
The  achloride  electrolyte^  therefore  amounted  to  0070  gram-mol. 
and  the  achloride/chloride  ratio  was  o-i6. 

The  omotic  concentration  waso-28i,  so  that  the  non-electro- 
lytes amounted  to  o-i68. 

The  chemical  examination  showed  a  trace  of  urea,  no 
purins,  a  trace  of  glycoproteid,  a  trace  of  invertase,  but  no 
diastase. 

The  a-naphthol  test  was  tardy,  b.t  the  glucosamine  test  instant 

and  intense. 

The  cellular  elements  consisted  mainly  of  lymphocytes. 


238  STUDIES   IN    I'L'NCTUKE-FLUins 

The  examination  on  three  <lifferent  occasions  gave  the  foilow- 
iii,7  results  : 


Ob'ervatiiin 


April  29.  J""e  7-  J"™    "• 


Specific  (iravity      

Albumen 

Urea 

Piirins 
Alljumoscs 
Monamino-arids     ... 

Luilhiii       

Cilvcoproteicis 

n-na(ilithol  test 

flliicosaniine  test   ... 

Concentration  ol  Kkctrolytes 
t  liloriiles 
Aehliirides 

Achloriile/chloriitc   ratio  ... 


1021 


1023 
6-;i  . 


6-95 


0 

0 

> 

. 

0 

0 

+ 

-r 

+ 

+    +   -r 

+   +   + 

+ 

0  IM 

0  III) 

01 23 

00  (3 

0042 

0070 

0070 

0074 

0053 

01 6 


17 


075 


1.  Will  be  seen  that  only  on  June  7  did  the  •'  salt  "  ratio  fall  m 
with  the  idea  of  an  inflammatory  effusion.  This  case  was  only  of 
••  idionathic  "  pleural  effusion,  and  was  presumably  tuberculous. 
Commail.-TheK  is  a  certain  amount  of  difl^culty  in  weighing 
up  this  case.  The  chlorides  being  relatively  low  indicates  an 
inflammatory  process,  although  the  total  concentration  of  electro- 
lytes was  also  low,  so  that  the  "  salt  "  ratio  is  not  constant.  On 
the  whole,  the  diagnosis  is  in  favour  of  the  pleural  effusion  being 
of  inflammatory  origin,  and  probably  tuberculous. 

IV.  William  A.,  aged  42.— A  milky  fluid  showing  no  siwn- 
taneous  coagulum  or  any  dei^sit  beyond  a  few  granular  cells. 

The  total  proteid  amounted  to  4-65  })er  cent.,  and  the  chlorides 

to  30  lier  cent.     The  concentration  of  the  achloride  electrolytes 

was  almost  equal  to  that  of  the  chlorides.     There  was  a  moderate 

amount  of  urea.     There  was  no  glycoproteid.     Cholesteim  was 

present.     The  tryptophane  reaction  was  positive.     As  regards 

ferments,  there  was  a  trace  of  diastatic  and  of  inverting  action. 

Comment.— l\w  microscopic  characters  and  the  "salt"  ratio 

are  in  favour  of  this  fluid  having  a  transudatory  origin,  although 

the  proteid-content  is  rather  high.     The  diagnosis  is  that  this 

fluid  is   a  chronic  effusion   in   which   there  may  at  first    have 

been  mflammatory  processes,  but  that  these  are  now  quiescent. 

V.  Mary  A.,  aged  34.— The  pleural  fluid  was  examined  on 

two  occasions,  but  with  an  interval  of  only  a  week  between  them. 


SPECIAL   CASES 


239 


The  turbid  greenish  fluid  (later,  blood-stained),  with  a  small 
amount  of  coaguluiii,  had  asj^cific  gravity  of  1020,  and  contained 
6  per  cent,  of  total  proteid  (only  058  j)er  cent,  globulin). 

The  chloride  electrolytes  showed  a  concentration  of  0035 
on  one  occasion,  the  total  electrolytes  amountmg  to  o  J46Q,  and 
the  achloride  electrolytes  to  01830.  The  achlonde/ chloride 
ratio  was  therefore  2S(). 

The  chemical  examination  showed  the  presence  of  a  trace  of 
invertase,  urea,  no  protalbumose,  no  glycojiroteids,  no  mon- 
amino-acids.  The  a-nanhthol  test  and  the  glucosamine  test  were 
positive  but  slight.  The  diazoreaction,  on  the  other  hand,  gave 
a  |)ositive  result. 

The  cellular  elements  were  mainly  lymi>hocytes. 
This  fluid  was  from  a  case  in  which  there  was  carcinomatosis 
of  the  jx-ritoneum,  the  primary  growth  being  in  the  ovary.     The 
pleural  effusion  was  of  inflammatory,  but  not  malignant  origin 
The  high  salt  ratio  and  other  fioints  will  be  nntcd. 

The  e.xamination  on  the  two  occasions,  when  compared, 
showed  no  appreciable  difference  ;  not  enough  to  justify  reproduc- 
tion of  tlie  findings  in  each  case. 

V'l.  Alfred  K.,  aged  28. ^An  amber-coloured  fluid  with  an 
abundant  coagulum,  had  a  specific  gravity  of  1022,  and  contained 
8  per  cent,  of  total  proteid,  of    which  only  a  small  projHjrtion 

was  globulin. 

The  concentration  of  chloride  electrolytes  was  0064  gram-mol., 
the  total  electrolytes  amounting  to  0-261,  and  the  achloride  electro- 
lytes to  0180.     The  achloride  chloride  ratio  was  therefore  .2-23. 

The  chemical  examination  showed  the  presence  of  invertase, 
urea,  albumose.  but  no  purins  :  no  serosamacin.  The -.-naphthol 
and  the  glucosamine  reactions  were  immediate  and  marked. 

The  cells  consisted  mainly  of  lymphocytes  and  red  cells. 

The  fluid  was  an  inflammatory  effusion  of  tuberculous  nature. 

VTI.  William  L.,  aged  21.— A  clear  yellow  fluid  with  a 
considerable  coagulum.  The  six;cific  gravity  was  1024  a.ul  i 
per  cent,  of  albumen. 

The  concentration  of  the  chlorides  was  0031,  while  that  01 
the  total  electrolytes  was  0-2319  ;  the  achloride  electrolytes 
amounted  to  0-1733  and  the  achloride/chloride  ratio  was  2-95. 

The   osmotic  concentration  was   o-2Cj<j  gram-mol.  jxjr  litre. 

The  chemical  examination  showed  0004  per  cent,  purin  N, 


240  STUDIES  IN    PUNCTURF.-FLUIPS 

albumoses.  but  no  monamino-acids.  The  a-naphthol  and  the 
glucosamine  reactions  were  immediate  and  mtense.  Globuhn 
formed  a  large  percentage  of  the  total  prote.d 

The  cdlular  elements  consisted  mamly  of  lymphocN  tes 
This  was  an  innammatory  fluid,  occurring  four  weeks  after 

^"^;n'Hti:rr:.ed6.-A  bright  yellow.co,onrj^  fluid, 
having  s,x.cific  gravity  of  T022.  contained  8  per  cent,  albumen^ 
The  concentration  of  the  chlorides  was  0-042  gram-mol..  whi  e 
the  total  concentration  of  the  electrolytes  amounted  to  0122. 
The  achlonde  electrolytes  therefore  amounted  to  0080  gram-mo!. 
and  the  achloride  chloride  ratio  was  19^. 

The  chemical  examination  showed   the   presence  of  mucli 
urea,  but  no  albumoses,  peptones,  monamino-ac.ds.  or  punns. 
The  cellular  elements  consisted  mainly  of  degenerate  pus-cds. 
This  was  a  fluid  from  an  empyema  associated  with  mastoid 
disease. 

(1?)  PERITONEAL   FLUIDS 
FioRENCE  W..  aged  ay.-The  fluid  is  alkaline,  and  has  a 
^    ^    L-ravity  of  1012.     It  does  not  coagulate  spontaneous  y. 
«  standing  deix)sits  some  flaky  lymph,   which   entangles 

...   :f  numl^er  of  cells. 

€  cdls  are  chiefly  granular  mononuclear  leucocytes,  and 
the, ,  are  relar:velv  fewer  polynuclear  leucocytes.     Besides  these 
the     i-  a  no.  ^considerable  number  of  large  cells  with  abundant 
cv        .sm       >d   relatively   very   small   nucleus.     Some    multi- 
nUMcteoe-  —some  having  three  or  four,  others  several  nuclei- 

were  also  -^^»<«Tved.  „   . ,   . 

TY^  Mrmual  examination  has  shown  that  the  fluid  is  corn- 
pa,  ativ  rich  in  chlorides  (oW.  iH.r  cent),  a.vl  that  there  is  about 
o-i  i)ei  c  t.  of  urea.  The  albumen  is  present  in  considerable 
but  not  in  excessive  amount  (1-95  I'er  cent.). 

The  osmotic  pressure  of  this  fluid  is  higher  than  that  normal 
for  blood  (equivalent  to  9  atmospheres  instead  of  7). 

The  urine  secreted  at  the  time  of  tapping  was  examined, 
and  found  to  have  as  si^cial  characters  a  high  spec.hc  gravity 
and  an  increased  quantity  of  urea.  It  was  practically  free  from 
chlorides,  while  the  osmotic  pressure  was  high,  and  caused  largely 
by  non-electrolytes. 


SPECIAL  CASES 
The  results  of  examination  are  tabulated  below. 


241 


Urine 

Periluneal 

I'rine 

Keritoneal 

Swrroted  a' 

Kluld 

1  SrcrrUd  at 

Fluid. 

time  of 

;  weeks 

t      lime  of 

TappiDf. 

later. 

1    TappirR. 

Specific  gravity 
Reaction        

1012 

al". 

rgranular  leucocytes, ~) 
1  larKo     bi  -  nucleate  1 
1  cclli,      mononuclear  1 
(.                ce'.li               J 

1030 
acid 

toll 

alk. 

1017 

acid 

Deposit 

red  urates 

0 

urates 

Urea 

00 1  % 

y2r. 

0 

i-9?^o 

Albumen        

•9S% 

0 

^■5'- 

nil 

Chlorides       

6-5  %o 

005°:, 

6-35     : 

'S^U 

Freeziiiji:  •  point      de- 

pression 

0591 

1950 

06C6 

\\(,o 

Osmotic  Concentration 

3'9 

1052 

0360 

0644 

Osmotic    pressure    in 

1 

atmospheres 

-•« 

234 

79 

143 

Conductivity  (22°  C.) 

1161 

1772 

1181 

lies 

Cone    of   electrolytes 

03^47 

O-20I 

0128 

0  120 

Cone,  of  achlorides  ... 

00851 

0  196 

0020 

0095 

Cone,  of  non-eltctro- 

lytes           

0014 

0851 

0232 

05J4 

C  clecf. 

C  noil  ilect. 

216 

023 

0-5S 

024 

C  achior.  | 

041 

097 

015 

079 

C  chlor.     ( 

Comment.— From  these  figures,  showing  the  changes  that 
have  taken  place  during  five  weeks,  it  will  be  seen  that  while 
the  two  specimens  show  a  similar  composition  as  regards  the 
most  essential  constituents,  the  urine  shows  slight  changes.  The 
amount  of  area  has  diminished,  and  that  of  the  chlorides  has 
increased.  The  concentration  of  electrolytes  has  also  diminished. 
On  this  change  there  can  be  laid  little  stress,  owing  to  the  fact 
that  urine  is  so  variable  The  constancy  of  the  composition  of 
the  peritoneal  fluids  is.  however,  important,  as  indicative  of  a 
stationary  condition.  The  ratio  of  electrolytes  to  non-electrolytes 
and  that  of  achlorides  to  chlorides,  following  the  rules  formulated, 
indicates  that  this  fluid  is  transudatory  in  nature. 

The  question  as  to  whether  there  was  or  was  not  tuberculous 
peritonitis  was  raised,  and  the  answer  to  that  was  as  follows  : 
Against  tubercle  (no  tubercle  bacilli  found) :  less  than  3  per  cent, 
albumen,  low  specific  gravity,  absence  of  spontaneous  coagula- 
bility, high  achloride/chloride  ratio.  Alone  in  favour  of  tuliercie 
was  the  presence  of  many  mononuclear  cells  in  the  deposit.     The 


242  STUDIES  IN    PUNCTURE-FLUllxS 

fact  that  this  preponderance  was  very  slight  did  not  influence 
one"'^  opinion  much  in  favour  of  tubercle. 

P  J-mortem  diagnosis  :    thrombose  of  the  PO^^al  vem    _ 

II    ELLEN  D    aged  50.-A  milky  fluid  of  specific  gravity 
1018-1019-1020.    The  fluid  was  not  spontaneously  coagulable. 

There  is  a  large  amount  of  albumen  present  (3  per  cent.). 
The  chlorides  amount  to  8  gm.  per  litre  (0137  gram-moL). 

The  osmotic  concentration  is  0272.  whUe  the  --e  secreted 
.U  this  time  showed  only  a  concentration  of  0^156.  T]>^  """^ 
had  a  specific  gravity  of  1005.  contained  no  albumen,  and  only 
X  per  cent,  of  chlorides ;  the  urea  was  0-25  P«r  ""*• 

The  electrolytes  consisted  almost  entirely  of  chlorides  the 
total  electrolyte  concentration  being  only  oi39  gram-mol.  per 

''^' The  deposit  was  considerable,  and  consisted  of  numeroi^  very 
large  mononuclear  cells  (some  bi-  or  tri-nucleate) ;  also  red  celU^ 
and  some  polymorphonuclear  leucocytes.  Some  of  the  cells 
contained  refractile  non-fatty  granules.  ,    ^  . .  •      -,>,,, 

The  percentage  of  albumen  indicates  that  the  fluid  is  either 
of  a  chronic  exudative  nature  (associated  with  either  hepatic 
trll  or  with  peritoneal  new  growth).  While  the  percent^e 
oLbumen  just  comes  within  the  limit  for  tuberculous  effusions, 
it  is  so  high  that  this  form  of  peritonitis  may  be  excluded. 


April  as.  '9°6- 
Abdomind. 


June  11,  1906- 
Abdominal- 


June  19, 1906. 
Pleural. 


July  19,190^. 
Abdominal. 


Specific  gravity  ...  j 

1020 

3% 

Albumen ' 

Cilycoproteid      ...  1 

3- 1 37  gm.-mol. 

Chlorides < 

Freezing-point  de- 

pression 

0502 

Osmotic    Concen- 

tration  

0-272 

Cone,   of   Electro. 

lytes     

0139 

Conc.ofAchlorides 

0002 

Cone,      of     Non- 

electrolytes     ... 

o«33 

Achloride/chloride 

ratio 

O'OI 

Deposit 

?  Sarcoma 

1020 

17 
0-113 


1018 

02 

0097 


0115 
0018 


Enormous  cells 
I    (sarcoma  ?) 
and  red  cells 


0-34 
Endothelial 

cells  and 
lymphocytes 


1019 

2 

present 

0-046 

0-679 

■358 

•223 

•177 

•»35 

2-62 

Numerous 

cell*  and 

amorphous 

coagulated 

proteid 


SPECIAL  CASES 


243 


The  fluid  is  an  exudate,  not  a  transudate. 

This  case  was  tapped  several  times,  and  was  found  to  show 
fairly  constant  composition. 

In  the  pleural  fluid  the  achloride  ratio  was  low,  just  as  at  first 
in  the  abdominal  fluid.  However,  the  latter  subsequently  showed 
the  normal  ratio  of  inflammatory  conditions.  We  might  assume 
that  the  pleural  fluid  was  not  of  an  inflammatory  origin,  and  that 
the  peritoneal  had  steadUy  become  inflamed  till  eventually  it 
was  actually  invaded  by  the  growth. 

Post-mortem  Diagnosis.— Round-celled  sarcoma  of  ovary  with 

peritoneal  dissemination. 

III.  Joseph  B.,  aged  36.— The  clear  straw-coloured  fluid  had 
a  specific  gravity  of  1012.  and  contained  08  per  cent,  of  albumen. 
There  was  a  small  amount  of  urea  present,  and  the  chlorides 
amounted  to  055  per  cent.  (0094  gram-equiv.).  The  cells  m  the 
deposit  were  mainly  endothelial. 

Physico-chemical  Examination.— The  osmotic  concentration 
was  0-360,  and  the  concentration  of  the  electrolytes  0135.  The 
achloride  electrolytes  amounted  to  0041  gram-mol.  per  litre,  so 
that  the  achloride/chloride  ratio  was  0-435. 

The  urine  secreted  at  the  same  time  as  the  fluid  was  tapped 
was  concentrated,  and  contained  a  copious  deposit  of  red  urates. 

The  fluid  was  examined  again  a  month  later,  and  found  to 
still  have  practically  the  same  characters,  and  the  urine  also  had 
very  simUar  characters,  as  wiU  be  seen  from  this  table  of  results. 


Ubcervation. 


Specific  Gravity 

Albumen 

Urea  

Chlorides 

Freezing-point  Depression 

Osmotic  Concentration 

Concentration  of  Electrolytes    .  . 
„  Achlorides 

Non-electrolytes 
Achloride/chloride  ratio 
Deposit     ... 


May  2,  iy-6. 


June  <>,  1906. 


Fluid. 


Urine. 


Fluid.      I    Urine. 


1012         j 

1036 

1013 

o-s°:     1 

none 

1-0% 

OOJ% 

3-3%      i 

none 

5'5%c 

3-5%.     i 

^Vh 

0667 

2405 

0658 

0360 

1-326     , 

0-355 

0135 

0-266     1 

0131 

0041 

0-207 

0-014 

0-225 

I  060 

0-224 

0435 

35 

OCt2 

lirfe  mono- 
nuclear cell* 

urates 

aameas 
bcfora 

and  lympho 

' 

cyt«»       and 

endoiheli* 

] 

cell* 

1 

t 

103s 

none 

3-65% 
0-7%* 
3-400 

I -3 16 
0-254 
0-243 
1062 

4;54    . 
aa  depoait 


244  STUl.ItS   IN    I'UNCTUKE-FLUIDS 

From  these  fads  one  arrive,  at  the  conclusion  that  the 

''"Thrnt™,^;".^™'::;,  a  .irrhos»o.  ,he  Uver  i„  an  advanced 

•a     fl^^l.i' received  foe  examinatton  at  diff.renl  fmes. 
pilf  „»,! Mh.    mud  ».   ,„und    .0    be   ,o/*,->*»    ■» 

"' mc  results  o(  examination  are  l«st  tabulated  ; 


Specific  Gravity 
Albumen 

Urea     i 

Chlorides 
Concentration  of 

Electrolytes 
Concentraticn  of 
Achloridcs  ... 
Achloride/chlo- 

ride  riilio     ...  1  °'*9 

Deposit  ...   •  Sporulating 

j       bacilli 
Chemical  notes     I  Excess  of  glo- 
!       bulin.        No 
I       glycoprotcid 

The  evidence  is  in  favour  of  a  transudate.  -"^^  ^^^^f  J^^^; 
content  is  high  and  the  achlonde-content  -ry^^;^  J^^^^ 
nature  of  the  case  is  difficult  to  explain.     The  following  account 
ofmLroscic  examination  of  three  of  the  organs  obtamed  at  the 

nprroDsv  will  sum  up  the  case  : 

S-M.croscop.c  examination  shows  an  extreme  degree 
of  fatty  infiltration  and  degeneration.  In  some  parts  the 
Uver  cells  have  almost  disapju^ared.  The  parts  m  which 
there  fno  change  are  few  and  far  between.      The  capillaries 

'"  p;!:cmis.-There  is  no  increase  in  the  amount  of  interstitial 
tissue.  The  islands  are  normal,  and  there  .s  no  evidence  of 
chronic  interstitial  pancreatitis. 


SPECIAL  CASES 


M5 


Kidney— The  only  abnormal  condition  is  to  Ik-  seen  in  the 
convoluteil  tubules,  where  the  epithelium  is  extremely  cloudy 
and  the  nuclei  are  in  most   places  lost.     In  other  parts  the 
tubules    are  apparently  quite  healthy.     The  glomeruli  cannot 
honestly    be    said   to  show   any   abnormality.     There    is    no 
increase   in   the  amount    of    mterstitial    tissue,    and    there   is 
no  leucocytic  infiltration.    The  straight  tubules  are   perfectly 
normal        The    convoluted    tubules    are     filled    with     finely 
granular    detritus,    and    in    some     places    this    matter    is   so 
abundant  as  to  form  what  would  be  hyaline  casts.     In  some 
parts  the  epithelium  of  these  tubules  is  much  swollen,  while 
in    others    it    is   low.     In    the    former    place    the    nuclei   are 
generally  present,  while  in  the  latter  they  are  often  absent. 
Hcie  and  there  the  capillaries  are  widely  dilated,  but  this  feature 
is  inconspicuoas.     In  short,    an  unprejudiced  observer  would 
not  diagnose  any  serious  renal  disease,  and  the  only  conclusion 
to  be  drawn  is  that  the  kidney  has  been  subjected  to  some 
serious    toxic    agent,   which    has    been   excreted  through   the 
epithelium  of  the  convoluted  tubules   and  damaged  it  during 

its  passage.  ,    •  u  j 

V    Harry  E.,  aged  30,  was  tapi^il  several  times,  and  yielded 

a  clear  amber-coloured  fluid  of  sj^ecific  gravity  loio  and  contam- 

ing  only  15  per  cent,  albumen. 

The  chloride  electrolytes  amounted  to  0088  gram-equiv..  and 

the  total  electrolytes  amounted  to  -2121  gram-mol.  per  litre,  so 

that  the  achioride,  chloride  ratio  was  0-26. 

The  acidity,  tested  by  Wright's  method,  was  equivalent  to 

HjSOi. 
^he  chemical  examination  showed  the  presence  of  much 
globulin,   of  serosamucin,  of    invertase.  but   no  albumoses  or 
neotones,  no  monamino-acids  and  no  diastase. 

The  deposit   contained    very   little    blood,-of  white   cells 
mostly  lymphocytes;     a   few    endothelial    ceUs,    none    bemg 

vacuolated.  .        , 

The  report  on  this  case  was  that  there  was  proliferation  of 

the  cells  of  the  serosa,  but  no  evidence  of  new  growth  or  tubercle. 

Most  likely  it  was  due  to  hepatic  cirrhosis. 

The  post-mortem  showed  the  case  to  be  one  of  monolobular 

cirrhosis  of  the  liver. 


It 
1000 


MICROCOPY   RESOIUTION    TEST   CHART 

(ANSI  and  ISO  TEST  CHART  No    2i 


1.0 


I.I 


m 

13.2 


I:  i^ 


2.5 
2.2 

[2.0 
1.8 


1.25 


1.4 


1.6 


^     .APPLIED  IIVMGE 


■  ■;-.       \f..j,r      'j-fer' 


i^Jl'*   -f.  New  ■.:,ri.    14609   j'^A 
,  ''6   d2  -  0300  -  Phone 
(716!  ?8H  -  5989  -  Fa» 


246 


STUDIES   IN    rUNCTURE-FLUIDS 


The  following  table  will  show  at  a  glance  the  condition  of  the 
fluid  on  different  occasions  : 


Obiervxion. 


Jan.  23. 1907. 


Feb.  a6, 1907.     !    April  10,  1907. 


Specific  gravity 

Albumen  

Urea     

Purins 

Amino  acids 

Albumoscs      

Glycoproteid   ... 

Ferments         

1 

a-naphthol  test  ...         •.• 

Glucosamine  test        ...  ...   j 

Chlorides  (gram-equiv.)        ... 
Osmotic  Concentration  ...  1 

Cone,  of  Electrolytes | 

Achloride       Electro-  1 

lytes 

Achloride/chloride  ratio        ...   | 
Cone,  of  non-electrolytes 


lOIO 

'  5/0 
trace 


1010 

1-7% 
none 

0-0021%  N 
none 


none 

none 
+  !  none 

!  trace  invertase, '    No  diastase, 
i     no  diastase     1  trace  invertase 


0113 

o-i68 

OC55 
047 


+  + 
0-088 

0'2I2 

0-0426 
0-26 


lOII 

s-s% 

moderate 
amount 


trace 

trace  invertase, 

no  diastase 

+ 


0-094 
0-300 


0-206 


VI.  Isaac  S.,  aged  23.— A  turbid  straw-coloured  fluid  of 
specific  gravity  1015  and  containing  2  per  cent,  albumen. 

The  chlorides  amounted  to  o'li  gram-mol.  per  litre,  the 
electrolytes  to  o-i2,  so  that  the  achlorides  were  001.  The 
achloride/chloride  ratio  was  therefore  001. 

There  was  no  globulin  present.  The  ceUular  elements  con- 
sisted of  a  few  mononuclear  leucocytes. 

The  "  salt  "  ratio  is  low  (exception  to  rule),  and  the  low 
percentage  of  albumen  is  in  favour  of  a  tuberculous  effusion. 
The  case  was  one  of  tubercular  peritonitis. 

VII.  William  D.,  aged  67.— A  turbid  straw-coloured  fluid 
of  specific  gravity  1017,  containing  8  gms.  per  litre  of  albumen. 
The  chlorides  amounted  to  o-io;  gram-mol.  per  Utre,  the 
electrolytes  to  o-ii8,  so  that  the  achlorides  were  ooii.  and  the 
"  salt  "  ratio  1-5. 

Chemical  examination  showed  no  glycoproteid.    The  cellular 
characters  were  of  most  interest,  and  are  shown  in  Plate  I. 

The  findings  indicate  an  effusion  of  inflammatory  origin  (low 
NaCl-content,  high  "  salt "  ratio,  high  albumen-content). 

The  case  proved  to  be  one  of  sarcoma  of  the  omentum,  with 
peritoneal  dissemmutiuii. 


SPECIAL  CASES 


247 


VIII.  John  K.,  aged  46.— The  turbid  fluid,  in  which  large 
white  particles  were  floating,  contained  2  per  cent,  of  albumen 
and  0"4  per  i  nt.  of  chlorides  (o'o68  gram-mol.). 

The  ek  irolytes  amounted  to  0132  gram-mol,  so  that  the 
concentration  of  the  achloride  electrolytes  was  0064  gram-mol.  ; 
the  "  salt  "  ratio  was  therefore  074. 

No  globulin  or  glycoproteid  was  found,  but  triple  phosphate 
crystals  were  present. 

The  cells  included  numerous  large  mononuclear  cells,  with 
abundant  non-granular  cytoplasm  and  also  some  large  multi- 
nucleate cells. 

The  salt  ratio  pointed  to  a  transudatory  fluid,  the  low  albumen, 
content  likewise  pointed  against  an  inflammatory  effusion,  while 
the  low  chloride-content  was  decidedly  against  a  transudation. 
On  the  other  hand,  the  absence  of  globuUn  or  of  glycoproteid 
seemed  to  indicate  a  transudatory  fluid. 

The  necropsy  showed  colloid  carcinoma  of  the  stomach,  with 
extensive  peritoneal  dissemination  ;  on  the  other  hand,  there 
had  been  a  tuberculous  pleural  effusion. 

IX.  George  W.,  aged  52.— A  straw-coloured  fluid,  forming 
a  small  coagulum  after  a  considerable  length  of  time,  had  a  specific 
gravity  1014.     The  albumen  only  reached  0-5  per  cent. 

The  chloride  electrolytes  amounted  to  0108  gram-mol.  (fairly 
high),  and  the  concentration  of  electrolytes  was  Ii2i,  so  that 
the  achlorides  amounted  to  0013  gram-mol.  The  " salt "  ratio 
was  therefore  083. 

The  osmotic  concentration  was  0-311  gram-mol,  so  that  the 
non-electrolytes  amounted  to  -070  gram-mol. 

The  chemical  examination  showed  abundant  glycoproteid 
(not  metalbumen). 

The  cellular  characters  were  insignificant— a  few  lymphocytes. 
In  this  case  the  low  albumen-content  and  the  fairly  high 
chloride-content  point  to  a  transudation.     The  salt  ratio  also 
indicates  a  non-inflammatory  collection.    The  presence  of  glyco- 
proteid is  peculiar. 

The  case  proved  to  be  one  of  back-pressure  from  tricuspid 
regurgitation  and  stenosis,  and  the  presence  of  glycoproteid  here 
falls  in  line  with  several  other  back-pressure  effusions  which 
have  been  examined  and  found  to  contain  a  reducing  body  after 
hydrolysis. 


248 


STUDIES  IN    PUNCTUKE-FLUIDS 


m 


i;! 
I 


X.  William  H..  aged  19.— A  highly  coloured  and  slightly 
glistening  fluid  of  specific  gravity  1018,  and  containing  a  con- 
siderable amount  of  albumen. 

The  fluid  deposited  a  thick  layer  of  finely  granular  pus,  with 
streptococci ;  the  polynuclear  cells  were  necrotic.  No  large  cells 
or  multinuclear  cells  were  seen. 

The  precipitation  limits  for  ammonium  sulphate  were  4-5 
and  0,  the  maximum  being  at  6.  There  was  a  trace  of  hetero- 
albumose,  and  some  protalbumose.  Glycoproteid  was  found, 
and  some  lecithin  The  a-naphthol  and  the  glucosamin  test  gave 
a  negative  result.  Leucin  and  tyrosin  were  absent. 
Physico-chemical  tests  were  not  applied. 
This  was  a  case  of  ascites  due  to  back-pressure  in  a  case  of 
adherent  pericardium  and  endocarditis.  Fat  necrosis  was  found 
in  the  abdomen. 

XI.  Walter  S.,  aged  36.— A  foul-smelling,  reddish-brown 
fluid,  containing  much  blood  and  a  small  amount  of  coagulum, 
had  a  specific  gravity  of  1013,  and  contained  775  per  cent, 
albumen. 

The  chloride  electrolytes  amounted  to  0043  gram-mol.  per 
litre,  and  the  total  electrolytes  to  2675,  the  achloride  electrolytes 
amounted  to  01875  and  the  arhloride/chloride  ratio  was  2-34. 
The  osmotic  concentration  was  high,  0406. 
The  chemical  examination  showed  the  presence  of  much 
urea,  purins,  of  serosamucin,  of  protalbumose,  and  a  trace  of 
phosphates.  The  a-naphthol  reaction  and  the  glucosamine  test 
were  prompt  and  intense.  Diastase  and  not  invertase  was 
found. 

The  cells  consisted  mostly  of  lymphocytes. 
This  was  evidently  a  case  in  which  there  was  some  inflamma- 
tory condition  of  the  peritoneum,  and  the  post-mortem  examina- 
tion showed  a  chronic  adhesive  peritonitis  with  a  coli  infection. 
XII.  Arthur  S.,  aged  42. — The  amber-coloured  fluid  had 
a  specific  gravity  of  1016  and  contained  25  per  cent,  albumen. 

The  chloride  electrolytes  showed  a  concentration  of  0-042, 
while  the  total  electrolytes  were  -211 ;  the  concentration  of  the 
achloride  electrolytes  was  therefore  133,  and  the  achloride/chlo- 
ride  ratio  i-68. 

The  osmotic  concentration  was  0-293. 

The   chemical  examination   showed   a   trace  of  urea ;    the 


SPECIAL  CASES 


249 


r 

i 


a-naphthol  reaction  was  slight,  and  the  glucosamine  tost  decided. 
Metalbumen  or  serosamucin  was  not  found.  There  was  a  trace 
of  invertase  and  no  diastase. 

The  cells  were  mostly  endothelial. 

This  was  a  case  of  monolobular  cirrhosis  of  the  liver.  Note 
the  high  salt  ratio. 

XIII.  Emma  N.,  aged  35. — The  turbid  straw-coloured  fluid 
had  a  specific  gravity  of  1013,  and  contained  3  per  cent,  albumen. 

The  chloride  electrolytes  amounted  to  01 19  per  cent,  gram- 
equiv.  and  the  total  electrolytes  amounted  to  o'i4q  per  cent., 
so  that  the  achlorides  were  0'03o  per  cent,  gram-mol.  per  litre, 
giving  a  "  salt  "  ratio  of  025  per  cent. 

Chemical  examination  showed  the  presence  of  much  globulin, 
and  of  purins,  and  of  albumose.  No  glycoproteid  was  found.  The 
diazoreaction  gave  a  positive  result,  as  also  the  tryptophane 
test.  There  were  large  vacuolated  endothelial  cells  and  lympho- 
cytes in  the  deposit. 

This  was  a  case  of  polyorrhomenitis,  but  the  high  chloride- 
content  and  the  low  "  salt  "  ratio  points  to  a  transudation.  Inas- 
much as  there  was  no  direct  evidence  of  inflammation  in  the 
serous  membranes,  one  may  conclude  that  this  name  "-itis  "  is 
not  strictly  accurate. 

XIV.  Alice  D.,  aged  44. — The  deeply  blood-stained  and 
spontaneously  coagulable  fluid  had  a  specific  gravity  of  1021 
and  contained  a  considerable  amount  of  albumen  (3  per  cent.). 

The  chloride  electrolytes  amounted  to  0104  gram-mol.  per 
litre,  and  the  total  electrolytes  amounted  to  O'lig,  so  that  the 
achlorides  were  0"0I5  and  the  "  salt  "  ratio  014. 

The  fluid  contained  098  per  cent,  globulin  ;  invertase  ;  prot- 
albumose,  urea,  but  no  glycoproteid. 

The  deposit  consisted  mainly  of  lymphocytes.  There  were 
mast  cells,  but  no  endothelial  or  carcinoma  cells. 

This  was  a  case  of  tuberculous  peritonitis. 

XV.  John  T.  I.,  aged  44. — The  deeply  yellow-coloured  fluid 
had  a  specinc  gravity  of  1016,  and  the  scanty  deposit  was  made 
up  mainly  of  polygonal  cells  like  endothelial  cells. 

The  chemical  examination  showed  226  p»,r  cent,  of  albumen, 
017  per  cent,  globulin,  and  4"63  gm.  per  litre  of  chlorides.  There 
was  a  large  amount  of  urea.  Amino  acids  were  not  found.  Albu- 
moses  Were  not  found,  but  a  trace  of  mucin  was  noted. 


250 


STUDIES  IN   PUNCTURE-FLUIOS 


.if 


This  was  from  a  case  of  effusions  into  all  the  serous  cavities, 
associated  with  dilated  heart  and  previous  pneumonia.  The 
effusion  was  of  transudatory  nature,  as  shown  by  the  specific 
gravity,  the  albumen-content,  and  the  considerable  amount  of 
chlorides.     The  other  tests  were  not  applied  in  this  case. 

XVI.  Anthony  S.,  aged  28.— A  straw-coloured  fluid,  having 
a  specific  gravity  of  1020,  and  containing  475  percent,  albumen. 

The  concentration  of  the  chlorides  was  0-037  gram-mol. 

The  osmotic  concentration  was  0-317. 

The  chemical  examination  showed  the  presence  of  urea,  but 
no  albumose,  or  glycoproteid,  or  ferments. 

The  a-naphthol  test  and  the  glucosamine  test  were  positive, 

but  slight. 

The  cellular  elements  consisted  of  large  mononuclear  cells 

and  vacuolated  cells. 

The  characters  fit  well  in  with  the  typical  signs  of  an 
accumulation  of  fluid  due  to  back-pressure;  the  case  was 
one  of  incompensated  valvular  disease  of  the  heart. 

XVII.  Florence  W.,  aged  23.— A  straw-coloured,  blood- 
stained fluid,  yielding  a  bulky  coagulum.  had  a  specific  gravity 
of  1022  and  contained  675  per  cent,  albumen. 

The  concentration  of  the  chlorides  was  0059  gram-mol.,  while 
the  total  concentration  of  the  electrolytes  amounted  to  0-128. 
The  achloride  electrolytes  therefore  amounted  to  -069  gram-mol., 
and  the  achloride/chloride  ratio  was  1-17. 

The  chemical  examination  showed  the  presence  of  stellar 
phosphates  and  oxalates  ;   no  monamino-acids  ;  no  ferments. 

The  a-naphthol  test  and  the  glucosamine  test  were  positive, 

but  slight. 

The  cellular  elements  consisted  mainly  of  lymphocytes  and 

red  cells. 

The  characters  are  in  accordance  with  the  diagnosis  of  tuber- 
culous   peritonitis— low    chloride-content,   high   "salt"    ratio, 

absence  of  ferments. 

XVIII.  Lucy  H.,  aged  23.— A  turbid  yellowish  fluid  of  specific 
gravity  1020  and  containing  2 1  per  cent,  albumen.  The  chlorides 
were  very  scanty,  amounting  only  to  0-05  per  cent. 

Metalbumen  was  found  on  examining  the  precipitate  after 
treating  the  fluid  with  thrice  its  bulk  of  absolute  alcohol. 

The  concentration  of  electrolytes  was  0-113  gram-mol.  o-*- 


SPECIAL  CASES 


251 


litre,  the  achlorides  being  0112  gram-moL,  so  that  the  electrolytes 
were  almost  solely  achlorides.  (Achloride/chloride  ratio  =■ 
1 120.) 

Examination  of  the  deposit  showed  a  very  large  amount  of 
cholesterin  crystals,  and  also  a  very  considerable  quantity  of 
fatty  acid  crystals.  There  were  some  granular  epithelial  celb, 
but  the  bulk  of  the  deposit  was  unorganised. 

Report. — The  fluid  is  most  probably  not  ascitic,  but  derived 
from  an  ovarian  cyst — to  judge  by  the  chemical  characters* 

Operation. — Multilocular  ovarian  cyst. 

Comment.— l\it  facts  in  favour  of  the  fluid  being  ovarian 
considerable  albumen-content,  very  low   chloride-content. 


are ; 


presence  of  metalbumen,  the  achloride/chloride   ratio,  as 
as  the  cholesterin  and  fatty  acid  crystals. 


well 


APPENDIX 


TABLE   I 

- 

For  ready  reckoning  of  Chlorides  from  No. 

DF  CC.  OF  Ammonium 

SULPHOCVANIDE   SOLUTION    USED 

cc. 

gm. 

1 
cc.           gm.      1     cc.              gm. 

cc. 

urn.             cc 

gm 

iixd. 

per  liUe. 

used.      p«r  litre.   u»ed.       per  litre. 

1 

used. 

per  litre,    used. 

per  litre. 

'          30    . 

.    O'OO 

26*0    .  ,     2*00      22'0    .  .    4"00 

180    . 

.    600       140    . 

.    800 

399  ■ 

•05 

•9     ••        05 

•9  ..     05 

•9    . 

.       '05             9    • 

•03 

•8    . 

.      -10 

•8    ..      -lo 

•8   ..      '10 

•8    . 

.      -lo         -8    . 

10 

7    • 

•15 

7    ••       15 

7   ••     '15 

7    • 

.      -15          7    • 

•      'li 

•6    . 

.       -20 

•6    . .      -20  1      -6    . .      '20 

•6    . 

•20          '6    . 

•2 

•5    • 

■25 

255    •■    225     21-3    ..   425 

17-5    • 

.      -25      135    • 

•23 

■4    • 

■       -30 

•4  . .     -30  !     -4  . .     -30 

•4    ■ 

.      "30           4 

.       30 

•3 

•       35 

•3    ••       35         -3    ••      '35 

•3    • 

•      -35          -3 

•35 

■2 

•       40 

•2    . .      -40  1      -2    . .      -40 

•2 

•40             '2 

.      -40 

•I 

■       45 

■I    ..      -45  1       •'    ••      "45 

•I 

.      -45          -I 

•45 

a9'o 

•       50 

25*0   . .    250  ;  2fo    . .   4"5o 

170 

.    650      13-0 

.   8-50 

28-9   . 

■55 

•9    ..       55         "9    ••      "55 

•9 

■      "55          '9 

■55 

•8 

•60 

•8    ..       60         -8    ..      -60 

•8 

.     -60         -8 

.      60 

•7 

•      -65 

7    ■•      '65         7    ••      "65 

7 

•     -63         7 

.     -65 

•6 

•      70 

•6    . .      70         -6    . .      70 

6 

.      70          -6 

.      70 

•3 

•      75 

24-5    ••      75     205    ■•       75 

i6-5 

•      75      12-5 

75 

'4 

.      -80 

•4    ..      -So         -4    ..      -So 

•4 

. .      -80         -4 

•80 

•3 

•       85 

•3  •  •  -85 ;  -3  •  •  -85 

■3 

..      -83         -3 

..      -85 

•2 

..       90 

•2     .  .        -90            -2     .  .        "90 

•2 

•90             '2 

. .     -90 

•I 

•95 

•I    ..      -95         ■!    ••      *95 

•I 

..      -95           I 

•  •      -95 

28-0 

..    100 

24'0    . .    3'oo     20'o    . .    5*oo 

l6'o 

. .    700      120 

. .    900 

27-9 

. .       05 

•9    ••      '05          9    ••      '05 

•9 

. .      05          9 

•05 

•8 

10 

•8    ..      -lo         -8    ..      -lo 

•8 

. .      -lo         -8 

10 

•7 

••     '15 

7    ••      "15         7    ••      "15 

7 

..      -15         7 

■15 

•6 

.  .       "20 

•6    . .      "20         -6    . .      "20 

•6 

•20          '6 

■20 

•5 

••        '25 

23-5    ••      "25     19-5    ••      "25 

155 

■  ■     -25      11-5 

■25 

•4 

•  ■    "30 

•4    ..      -30         4    ..      -30 

•4 

. .      -30          '4 

..       30 

•3 

••      "35 

•3    •■       35         "3    ••       35 

•3 

•  •      -35         -3 

•35 

•2 

..      -40 

•2     .  .        40           "2     .  .       "40 

•2 

■40             -2 

..      -40 

•I 

•  •      "45 

•I    ..      -45         ■!    •■      "45 

•1 

..      -45         -I 

•45 

27'0 

..    1-5" 

230    ..    350     190    ..    550 

150 

..    7-50      110 

..    950 

26-9 

•      "55 

•9    ..       55  ;      '9    ••       55 

•9 

•  •      ■«         "i 

..       55 

•8 

..      -60 

•8    . .      -60         -8    . .      -60 

•3 

. .     -60         -s 

..      -fto 

•7 

..      -65 

7    ..      -65         7    ••      "65 

7 

..      -65         7 

..      -65 

•6 

••      70 

•6    . .      70  ,      -6    . .      70 

■6 

. .      70    ,      -6 

..      70 

•5 

•■      75 

22-5    . .      75  :  i8-5    . .      75 

145 

•  •      75      10  5 

..      75 

•4 

..      -So 

•4    . .      -So         '4    . .      "So 

•4 

. .      -So    !       -4 

..      "So 

•3 

■•      -85 

■3    ■  •      -85         -3    •  •      -85 

•3 

..      -85          -3 

..      -85 

•2 

..      -90 

•2     .  .        "90    i         '2      .  .        '90 

•2 

■90  :     "2 

..      -90 

•I 

••      '95 

•I    ..      -95  '       •!    -•      ■'>5 

!        •! 

•  •      -95          •! 

--      -95 

26'0 

..     2'0O 

1  22'o    .  .    4'oo 

1  i8'o    . .   6-00 

!  I4'0 

. .   8'oo   i  lo'o 

. .  1000 

2-53 


iri 


254 


APPENDIX 


TABLE    II 


APPENDIX 


255 


TABLE   U— continue  J 


Gm.   /       Gia.-i»ol. 


Mol«.+     '' 
knu. 


Cm.  / 


Gm.'inol 


iun*. 


3' 
525 

33 

3'33 

34 

543 

35 

355 

3<' 

5"5 

57 

573 

5-8 

5-85 

59 

5-95 

6'cxj 

605 

6- 10 

615 

62 

6-25 

63 

6-35 

6-4 

6-43 

6-3 

''•53 

6-6 

665 

67 

^75 

6-8 

685 

6-9 

695 

7"oo 

7''35 
7-10 

715 

72 

7-25 

73 

735 

7'4 

745 

7"5 

753 

7-6 

77 
775 


0088 

o"o89 

0090 

0*091 

0'092 

0-093 

0094 

0093 

0-095 

0*096 

0097 

0*098 

0*099 

0*100 

0*101 

0*102 

0*103 

0*104 

0*105 

0*105 

o*lo6 

0*107 

0*107 

o*lo8 

0*109 

0*110 

0*1  II 

0-II2 

0*113 

0*114 

0*115 

0*116 

0*116 

0*117 

0*118 

0*119 

0*120 

6121 

0*122 

0*123 

0*124 

0*124 

0125 

0*126 

0127 

0128 

0*129 

0*130 

0131 

1132 

o*M3 

0*134 


845 
845 
•844 
■844 
•843  ! 
•843  i 
842     ! 

•842  I 
■841  I 
•841     1 

•841     I 
840     i 
■840 
•839 
■838     ; 
•838     i 
•837 
•837 
•837     i 
•837     ' 
•837     i 
•836     i 
■836     I 
836 
•833     I 
•834 
•834 
•834 
•833 
•832 
•832 
■832 
■831 
•831 
•831 
•831 
•830 
•830 
•830 
•830 
829 
829 
*829 
*828 
•827 
•826 
•826 
*826 
•825 
•825 
•82s 
*824 


1623     , 

7-8 

1642 

7-83 

1659 

7  9 

*i678 

7'95 

16CJ5 

8*00 

•J713      1 

8*05 

•1731 

•I 

•173» 

•>3 

•1748 

•2 

1767 

25 

•1785 

•3 

•1803 

•33 

1821 

•4 

*i838 

•43 

•1856 

•5 

•1874 

•33 

•1892 

•6 

*l9JO 

65 

*l9i8 

7 

•1928 

75 

•1947 

*8 

*1964 

•85 

•1965 

•9 

•1982 

•95 

2000 

900 

*2017 

05 

•2035 

1 

*2o54 

■13 

•2055 

'i         -2 

•2088 

;i    -25 

*2io6 

•3 

2113 

•35 

2123 

■4 

2142 

•43 

*2l6o 

•5 

*2178 

■55 

*2200 

i       -6 

*2214 
•2232 
*2250 
*2267 
•2267 
*2286 

•2303 
•2320 
■2337 
•2338 
•2383 

•2390 

*24i8 
•2436 
•2410 


65 
7 
75 
*8 

•85 

•9 

•95 
10*00 
10*05 

*1 

•15 

*2 
•25 


•35 


0*134  I 

0*135  ; 

0*135  ! 

0136  I 

0137    ! 

0*137     I 
0*138 
0*139     I 
0*140 
0*141      \ 
0*142 
0*143     ' 
0*143 
0*144 

0*145 
0*146 

0*147 
0*148 
0*149 
0*150 
0*151 
0*151 
0*152 
0*153 
0154 
6*  1 55 
0155 
0*156 

01 57 
0*158 

01 59 
o*l6o 
0161 
0*162 
0*162 
0*1'  3 
0*104 
0*165 
0*166 
0*167 


•167  1 
0168 
0*169  ; 
0170 
0171 
0171 
0*172 
0173 

0174  I 

0175  I 
0*176    I 

0177     i 


■824 
■824 
•824 
•823 
•823 
•823 
•822 

1"  I 
■822 

•822 

•821  I 

•821 

*821  1 

•821  ' 

■820  i 

*82o 

*820 

•819 
819 
819 
819 
819 
*8io 
818 
■818 
•818 
817 

•817 

*8i6 

*8l6 

•816 

•815 

•815 

•813 

•815 

•814 

*8l4 

;  -813 

I  -813 

i   812 

1   *8l2 

'   *8l2 

■812 

!  -811 
•811 
•811 


*8lo 
•810 
*809 
809 
809 
•SoS 


•244*1 
*2463 

246a 
•2479 

2470 

2497 
•2514 
•253 « 
•2550 
■2573 
•2585 
-2604 
*2604 
■2622 
•2640 
•2657 
•2675 
•2692 
*27io 
•2728 
•3746 

•2746 
•2764 
•2781 

•2799 
*28i7 
*28i5 
•2834 
•2847 
•2869 
2887 
*2904 
•2920 

•2940 

•2940 

2956 

2974 

•2991 

j  -3009 
3027 
■3026 
•3044 
■3062 
307a 
•3096 
•3096 

!    i^ii 

3131 

•3147 

I  -3165 

!     3183 

•3200 


It  I 


25^ 


APPENDIX 


TABLE    111 

specie  ConauctivUv  o.  c>-nor.a.  and  J..n.uanorn.a.  so.ut.on,  of 
•^  I'otassium  Chlorulc. 


At  i6' 


it  is  001072  for  ^  KC»  and  ooo2294*  <or  |  KG. 


S 

20° 
21' 
22" 
23° 
24° 

26" 
27° 


1095 
III9 
1 143 
iif)7 
119' 
1215 
1239 

I2''4 

1288 
1313 
1337 


•002345 
•002397 
•002449 
•002501 

■002553 

•O02'>0'> 
•002659 
•002712 
•002765 
■002819 
•002873 


Temperature  co-efficients  ; 
NaCl    1 
,.      05 


gm.  equiv.  per  litre  =    -0238  j 


Correct       I 

let  ween     -. 

a  and  34°C.   I 


o': 

O'Ol 
O'OOI 

•05 

•01 

•001 

•0001 

•00005 


0238 

'°***?  \  Correct  uciwcvi 
-"^■^^i  26  and  40^  C. 
•0254 


I  Correct  between 


('..vcn  the  conductivity  at  18  C, 

*  i.e.  229^4  X  10 


=    •0253.' 
=  -02238  (c) 
=02255 
=  -02269 
=  •02284 
=  -02273 

tt  -  i8)-]. 


•oooo795'-C. 
848  ., 
850  ,. 
740  „ 
901  „ 


114 


APPENDIX 


257 


TABLE   IV 


Ratk  or  Mic.BATioN  or  loss. 


•0003  gn>.  cquiv.  per  litre 

•001 

•ooj  ..  '• 

•005  ••  " 

•01  ••  " 

•03  ». 

•05  .. 


Na 


43' 
4i'> 
4i4 
41'4 
405 

3»-3 

35■.^ 


Cl 


f>4-H 
'•44 

ityo 

fli'O 

yi>» 
VS'. 
5"S 


ito. 


60 
66 
60 
35 

47 

3* 


TABLE   V 


Obach's  Table 


0  0000 

1  -ooio 

•OOiO 

■0030 

•0040 

■0050 

•0060 
■0070 
•0081 
■cog  I 


2 
3 
4 
5 

6 

7 
8 

9 


10  'OIOI 

11  -on  I 
'OI2I 
■0132 

14  '0142 

15  o'S^ 
•0163 

•0173 
•0183 


12 

13 


16 

«7 
18 


100 

■nil 
•1123 
•I  136 
■I  148 
•I  161 

•1173 
•1186 

1198 
-1211 
•1223 


19     0194 


•1236 
•1249 
■1261 
•1274 
•1287 
•1299 
•1312 

•1325 
•«337 
•1351 


20  -0204 

21  0215 

22  0225 

23  0235 

24  -0246 

25  0256 

26  -0267 

27  "0277 

28  0288 

29  -0299 


300  aoo 


■2500 
■2516 
•2531 
•2547 
•2563 
■2579 
•2594 
•2610 
•2626 
■2642 


•1364 
•1377 
•1390 

•J  403 
■1416 

■1429 
•1442 

•1455 
•1468 
•1481 


•4306 
•4327 
•4347 
•4368 
•4388 
■4409 
•4430 

•445« 
•447* 


400 

•66^)7 
•f.694 
•6722 
•6730 
•6779 
•6807 

•6835 
•6863 
•6892 
•69* ' 


•2638 
•2674 
•2690 
•2706 
■2723 
■2739 
•2755 
•2771 
•2788 
•2804 


•4493 
•4514 
•4535 
•4556 
•4577 
•4599 
•4620 
•4641 
•4663 
•4684 


•2820 

•2837 
•2853 
•2870 
•2887 
•2903 
•2920 
•2937 
•2953 
•2970 


soo 

i-jooo 
I  0040 
j-cx)8o 
1-U121 

I-Olfjl 
I'O202 

10243 

1-0284 

10325 
10367 


600        700        too        00 


•6949 
■6978 
•7007 
•7036 
•7065 
•7094 
•7'23 
•7«S3 
•7182 
•7212 


•4706 
•4728 
•4749 
•477> 
•4793 
■4815 
•4837 
•4859 
■4871 
•4903 


•7241 
•7271 

•730' 
•7331 
•7361 
•7391 
•7422 
•7452 
•7483 
■75'3 


1-500 
1-506 

1-513 
I-5«9 
1-525 
1-532 
1-338 
1545 
I-55« 
1-558 


1-0408 
I  0450 
1x492 

10534 
1-0576 
1-0619 
l-o66l 
I  -0704 
1-0747 
I -0790 


I  564 
1-571 
1-577 
1-584 
1-591 
1597 
1-604 
1-611 
1618 
1-625 


1-0833 
1-0877 
10921 
1-0964 
1-1008 
1-1053 
1-1097 
11142 
11186 
1-1231 


2333 
2-344 
2356 

2367 
2378 
;i-390 
2-401 
2-413 
2425 
2-436 

2-448 
2-460 
2472 
2484 
2-497 
2509 
2-521 
2534 
2-546 
2  559 


4-000 
4023 

4-051 
4-076 
4-102 
4128 

4-155 
4-181 
4-208 
4-236 

4-263 
4-291 
4-319 
4348 
4376 
4*405 
4435 
4464 

4-495 
4-525 


1632 
1-639 
1-646 

1*653 
1-660 

1-667 
r674 
I -68 1 
l(.88 
1-693 


2571 
2-584 
2-5^7 
2-610 
2-623 
2-636 
2-650 
2-663 
2676 
2-690 


9'Oo 
9-10 
9-20 

93» 
9-42 

953 
9-64 

975 
987 

9'9'> 

lo-iF 

io'24 
10-36 
10-49 
10-63 
10-76 
10-90 
II  05 

1 1 '20 
11-35 


4556 
4587 
4-618 
4650 
4-682 
4-714 
4-747 
4-780 
4-814 
4-848 


1:  50 
11-66 
11-82 
11  99 

12-l6 

.12-33 
12-51 

12-70 
1289 
13-08 


17 


258 


APPENDIX 
TABLE  W— continued 


Obach's  ^^al.E-cnulinued 


!•! 


30  '0309 

31  -0320 

32  -0331 

33  '0341 

34  '0352 

35  •03f'3 

36  -0378 

37  "0384 

38  -031)5 

39  '0400 

40  -0417  * 

41  -0428  • 

42  0438  ■ 

43  ■°449 

44  -0460 

45  '0471 

46  -0482 

47  ■°493 

48  -0504 

49  '0515 

50  -0526 

51  -0537 

52  -0549 

53  °5^° 

54  -0571 

55  "OSS^ 

56  -0593 

57  -0604 

58  •0616 

59  -0627 

60  '0638  ■ 

61  -0650  • 

62  '0661  ■ 

63  -0672 

64  -0684 

65  -0695 

66  -0707 

67  -0718 

68  -0730 
6y  -0741 

70  -0753 

71  -0764 

72  -0776 

73  -0787 

74  -0799 

75  '0811 
7(1  -0823 

77  '0834 

78  -0840 

79  -0858 


V  ' 


APPENDIX 


259 


TABLE   V — coniintud 

Obach's    Tkble— continued 


a  0 

80  "08  70 

81  •0881 

82  '0893 

83  -0905 

84  -0917 

85  -0929 

86  '0941 

87  "0953 

88  -0965 

89  -0977 

90  "0989 

91  -looi 

92  -1013 

93  '1025 

94  •1038 

95  'lojo 

96  -1062 

97  •i°74 
9?  -1086 

99  "1099 
loo  •ilii 


432 


FF  <^   to  find  -^  '*-^— '  .  look  down  the  400  column  till  32  of  column 
,   ■  is  reached,  the  number  7606  is  the  one  required.] 


26o 


Arri"Ni'i>^ 


■».-ij3iiil^'imiV 
in  Jill'-- ^J.l 


.„.,„..u^M„o     %%  ?  U  ^>.  :=■■  r-  '^-^rr.rr'r-  -  -  -  r.  -  -  -  ^  .-^ 

•uol-ojcI.Kl  *■?>?-    ~  ?■.-.".-.'    ."    •'   •"   •"•"•'•'■     •     ■     '^  ',.  '_  ■-. 


-aiainUrallV 
111  .un^siia 


niji  HUSO 


Uill>r3a4l-''<I 


>313II(IfOUl-lV 

ni  iiu^vaia 

•noi-iri'iua:iuto 
rmoia*0 


uoirsaiilaa 


boo 


-■r-,-r^'ro^^5:X5i:J^:r-.r.  t:t 

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APPENDIX 


261 


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LITERATURE 

The  followng  references  apply  to  the  authors  quoted  in  the  text.  As 
a  rule,  the  title  of  the  Journal  and  the  year  are  sufficient  to  identify 
the  reference,  so  that  its  title  has  not  been  considered  necessary. 

Some  of  the  references  here  given  have  not  been  definitely  quoted 
in  the  text,  though  they  have  been  made  use  of.  On  the  other 
hand,  many  references  in  the  Biochemische  Zeitschrift  and  the 
Biochemical  Journal  have  not  been  inserted,  since  nearly  every  one 
of  the  papers  which  have  appeared  from  the  very  commencement 
of  each  of  these  valuable  Journals  has  been  found  of  use  in  the 
studies  recorded  in  this  work. 

The  text-books  and  other  published  works  which  have  been 
made  use  of  appear  in  the  appropriate  places. 


SECTION    I 

Abderhalden  and  Barker.     Zeit.  f.  physiol.  Chem.,  xlvii.  524 
Abderhalden  and  Kemp.     Zeit.  f.  physiol.  Chem.,  lii.  207 
Albrecht.     Deut.  Zeit.  f.  Chirurg.,  Ixxxvi.  2-4 
Allers,  R.  A.     Biochem.  Zeit.,  vi.  272.     "  Uber  racemisches  Trypto- 
phan " 
Asher.     Biochem.  Zeit.,  ii.  i.     "  Beitr.  z.  Physiologic  d.  Driisen  " 
Bayer,  Gustav.     Biochem.  Zeit.,  v.   368.     "  Untersuchungen  uber 

die  Gallenhaemolyse  " 
Bayliss.     Biochem.  Journal,  i.  i;5 
V.  Bemmelen.  Zeit.  f.  anorg.  Chem.,  23,   1900 

Bosanquet,  C.     Lancet.     May  18,  1907 

Danilewsky.     Zeit.  f.  Biol.,  44 

Dencks.     Miinch.  med.  Woch.,  37,  1907 

Devillard.     Bull.  soc.  Chim.,  xlix.  611 

Devoto.     Journ.  of  Pathology.     1895 

Deycke  and  Ibrahim.     Zeit.  f.  klin.  Med.,  Iviii.  S,  6 

Eichholz.     Journ.  of  Physiol.,  xxiii.  176 

Erben,  Zeit.  f.  physiol.  Chem.  43. 

Folin.     Zeit.  f.  physiol.  Chem.,  xxxviii.  161,  1902 

Franchini.     Biochem.  Zeit.,  vi.  210 

S.  Frankel.     Descriptive  Biochemie.     1907 

263 


if/>7 


1Q03 


264  LITERATURE 

Freun<l  and  Joachim.     ZcU.  f.  /-/-vs/o/.  Che,,,.,  xxxvl.  4. 

vurnunu^t.     i^        _    ,    -.     ,,.       ••  rbcr    den    Lecithingchait    des 
Glikin.     Binche,,,.  Zett,  iv.    -\?v  \,        ■        ,. 

Knochcnmarks  bei  Ticrcn  and  bcim  Menschen 

Hr'liburton.     Lancet.     May  4-   '"*'/' 

H   mburccr.     Biocheni.  Zeit..  iii.  35'' 

"   "raTsten.     LehrkucI,  d.  pkysiol.  Che,,,.     4"  Auflage,  .«.>9 

I  edin.     Zeit.  f.  physiol.  Chem..  21 

Hedin,  S.  G.     Biocheni.  Journ..  1.  4'^4 

Henschen.     Zeit.  f.  klin.  Med.,  Ixiii.  1-4 

Hobcr.     Physik.  Che,n.     ic)oft 

Hofmeister.     Zeit.  f.  physiol.  Che,n.,  iv.  2,3.  1880 

V    Hoist.     Ze.t.  f.  physiol.  Chem.,  4H 

Hopkins  and  Cole.     Journ.  of  Physiol.,  2Q.  1003 

Hopixs-Scvlcr.     Physiol.  Chemte. 

Hosch      Deutsche  Zeit.  f.  Chirurg..  xc.  1-3 

Moscn.     i^cHiiwi  '  A„uiiunB  z    Analyse  des  Hams. 

Huppert,  Ncubauer,  and\ogcl.     Anlettung  z.  .i"'"y 

1800 
V.  Jaksch.     Klinische  Diagnosttk.     1004 
Joachim.     Pfliiger's  Archiv,  03 
Joachim.     Miinch  med.  WocU..  44- 
Jollcs.     Wien.  med.  Woch.     1804 
Jolles.     Munch,  med.  Woch.,  3.  1008. 

«   Aerzte.  Dresden,  IQ07 
Jollel'     li.  /.  P/O'-^-/.  Chen,.,  xxv.  236  ;   Z.7.  /•  hl.n.  Med.,  xxx.v. 

53,   '89« 
Kofmann      £>'e<'6.  rf-  J°''.vs.,  i-  1-28? 
KrS^r  and  Schittenhelm.     Z..7.  /.  physioL  Che,n.,  xxxv.  .54 

Kutsche.     Zeit.  f^^^y^'-^'-'H'-^X  Lecithide  der  Schlangen- 
Kyes.     Btochem.  Zett.,  n.  09-        ^  "^' 

gifts  " 
Landwehr.     Zeit.  f.  physiol.  Chem.,  v.  375 
Lancstein.     Jahrb.  Kinderh.,  Km.  925 

Levene  and  Rouiller.     B,ochem.  Zer.,  -v.  322.         ^oct  .1 

phangrupiio  im  Protcin-molekui;' 
T    J    •     o„.i  7oT-npV      Z£i7    /.  physiol.  Che,n.,  p.  23/ 

mtiirlichen  Lecithins  " 
Michaelis  and  Rona.     B../...  Z«7..  ii.  2,9.  iii-  109.  iv.  :2.  v.  36;. 

Mitiukoff.     Arch.  f.  Gyncikologie,  49 
Melon.     Gazz-d.  Osped.  Padua,  p.  149.  1904 


7g  Versamml.  Dent.  Xaturf. 


LITERATURE 


265 


Moore,  F.  C.     Medical  Chronicle.     December  1007 
Morgcnroth.     Biochem.  Zeit..  iv.  24«.     "  Ubcr  Toxolccithide  " 
Morner.     Shand.  Arch.  f.  Phys..  vi.  }}2,  1805 
Muller.     Mitteil.  a.  d.  tned.  Klinik  zu  Wtirzhiirg,  \.  :.<«5.  ^50 
Nakavama.     Zeit.  f.  phvsiol.  Chem.,  xxxvi.  y,H 
Nenski  and  Zaleski.     Zeil.  /.  phvsiol.  Che,,,.,  xxxiii.  2,17.  K'Oi 
Neubauer.     SiUber.  d.  Gesell.  /.  Morph.  u.  Physiol.  1,1  Munchen,  u>^^^ 
Neuberg.     Biochem.  Zeit.,  vi.  zjf^.     "  Verschiedenes  iibcr  Trypto- 
phan " 
Neuburg  and  Strauss.     Zeit.  f.  physiol.  Che„i..  xxxvi.  2.^ 
Niosi.      Virchow's  Archiv,   u«) 
Oerum,     Maly's  Jahrb..  xiv.  450 

Ohrmeycr  and  Pick.      \Vie,\.  kliti.  Rundschau,  p.   15.  i'X)2 
Otolski.     Bioche,n.  Zeit.,  iv.    124.     "Das    Lecithin  des   Knochcn- 

marks  " 
Otori.     Zeit.  f.  physiol.  Chetn.,  43 

Paijkull.     Zeit.  /.  physiol.  Chein.,  xii.  106 

Porges.     K.  K.  GeseUsch.   d.  Aerzte  in  Wien,  1008 

Reben.     Zeit.  f.  physiol.  Chenu.  xliii.  320 

Rcissner.      Virchow's  Archiv.  xxiv.  iQi 

Rivalta.     Riforma  Medica.  1805  ;    il  Policlinico,  kk)4 

Salkowski.     Practicum  d.  physiol.  n.  pathol.  Chen,.,  190. 

Salkowski.      Virchow's  Archiv,  131 

Sarzin.     Inaug.  Dissert.,  Berlin,  1894 

Schmiediberg.     Arch.  /.  exp.  Path.,  vii.  166 

Schulz.     Die  Crosse  des  Etweissmolekiils,  ick>3 

Soldner.     Zeit.  f.  Biol.,  xxxviii.,  237 

Stahelin.     Miinch.  med.  Woch.,  34.  1902 

Tollens  and  Krober.     Zeit.  f.  angewandle  Chem.,  iW2 

Toyosunii.     Mtinch.  med.  Woch.,  40,  igo" 

Umber.     MUnch.  med.  Woch.,  28,  igo2  ;  Zat.  f.  klin.  Med.,  48 

Weisz.     Beitr.  z.   Klinik.  d.    Tuherk.,   viii.   2  ;     Wien.  kltn.    Woch., 

xxxiii   7 
Willanen.     Biochem.    Zeit.,    i.    108.      "  tJber   das    Verhaltens    des 

Ovomukoids  im  Organisnius  " 
Zangerle.     Miinch.  med.  Woch.,     13,  iQOO 
Zanetti.     Ann.  di  chini.  e  Far,nacologia,  xxvi.  12 


FERMENTS 

Ascoli  and  Izar.     Biochem.  Zeit.,  vi.     "  Beeinfliissu.ig  dar  Autolyse 

durch  anorganische  KoUoide  " 
Ascoli  and   Bonfanti.     Munch,  med.    Woch.,    n)02,    1904:    Zeit.  f. 

physiol.  Chem.,  43 
Baer.     Miinch.  med.  Woch.,  44,  1906 


266 


LITERATURE 


"  The  Dia8» 


Bainbridgc  and    Bcddanl.     Biochem.  Joun,..  ii.  «0. 

tatic  Ferment  in  Tissues  in  Diabetes  Mellitus 
Bartarelli.     Rhisla  d'Igiene  e  Sanild  pubblica,  ic>04  ^^ 

Beam  and  Cramer.     Biochem.  Journ.,  ii.  174-     "  Zymo>^» 
Beitzke  and  Xcuberg.      I'erh.  d.  deutsch.  pathol.  Gesellsch.,  1904 
filum  and  Fuld.     Brochem.   ZeU.,  iv.  6..     "  Die  Best.mmung  des 

Fermentcehaltes  im  menschlichen  Magenmhalt 
Bredi,      Biochem.   Zeit.,   vi.    283  ;      "  Altes   und    Neues  von   der 

Katalvse  " 
Burian.     Zeii.  /.  physiol.  Chent.,  xliii.  509 
Chvostek.     IVien.  klin.  Woch.,  i»()(y 
V.  Dalmady  and  v.  Torday.     Bericht  aus  d.  biolog.  SUz.  am  3.  April 

1906 
Dastre.     C.  R.  Soc.  Biol.,  Iv.  130 

Delezcnne.     Comptes  rendus,  1903  j      »   * 

A.  V.  Drjewzki.     Biochem.  Zeit.,  i.  234.     "  Beemfliissung  der  Auto- 

lyse  durch  Alkali  " 
V   Dungern.     Die  Aniik'drper,  igo6 
Ehrlich  and  Morgenroth.     Berl.  klin.  Woch.,  1899-1902 
Eppenstein.     Munch,  med.  Woch.,  45.  ">o6 
Erben.     Zeit.  f.  Heilk.,  24;   ^"'-  /•  ^in.  Med.,  40:   Hofmeister  s 

Evani"' BiL^m.   /owrw.,  ii.  i33-     "On  Catalytic  Decomposition 

of  H,0, " 
O.  V.  Fiirth.     vii.  Internat.  Physiol.  Congress,  1907 
Fush.      Verein.  f.  inn.  Med.  zu  Berlin,  v-ii.,  1907 
Hamburger.     Fol.  haematolog.,  ii.  1905.  »  .  »   *•*    _;„  » 

S.  G.  Hedin.     BiocA.m.  Journ.,  i.  474-     "  Trypsm  and  Antitrypsin 
Hedin      Biochem.  J omn.,  '\i.  \12 

van  Itaaie.  Soc.  de  Biol.,  January  20.  1906.  "  Verslagen  van  d, 
Koninklyke  Akad.  v.  Wetenschappen  te  Amsterdam  mssen- 
naturkundige  afdeeling,"  p.  540,  1905-  ^^ 

Jacoby.     Biochem.  Zeit.,  i.  53.  "•    i44.   ^47,   iv.    21,  47 1-        i^er- 

mente  und  Antifermente  " 
lastrowitz.     Biochem.  Zeit.,  ii.  15? 
JoUes.     76  F^rsamm/.  deut.  Naturf.   a.  Aerzte,  Breslau.   1904,  and 

Miinch.  med.  Woch.,  47,  1904 
Klemperer.     Miinch.  med.  Woch.,  p.  I4S4.  I907 
Kiittner.     Zeit.  f.  physiol.  Chem.,  1.  494 
Leber      Die  Entstehung  der  Entzundung,  Leipzig,  1891 
Liebmann.     Klin.  Untersuch.  a.  d.  .-Ibteilung  B  des  Kgl.  Fretdrtchs 

Hasp.  Copenhagen,  1907  _ 

Lockemann.     "  79   Versamml.  deut.  Naturf.  u.  Aerzte  tn  Dresden, 

1907 
Lohlcin.     Hofmeister' s  Beitra^e,  vn.  120 


LITERATURE 


267 


Michaelis.     Deut.  med.  Woch.,  1004 

Migliarini.     Riv.  Ven.  di  Scienxe  medicaU,  xxi..  2.  3,  i<>04 

Molon.     Gazz.  d.  Osped.  Padua,  140.  ">o4 

Morgenroth.     Zentralbl.  f.  Bacteriologie,  xxvi.  uo 

Ed.  Miiller.     Deutsches  Arch.  f.  klin.  Med.,  xci.   13;  Munch,  med. 

IVoch.,  53,  ifX)7  - 

Miiller  and   Jochmann.     Mtinch.   med.  Woch.,  20,  31.  4i.  43-  "»" 
Nickel.     Die  Farhenreactionen  der  Kohlehydrate.    Berlin,  19CK       vH. 

Peters) 
Opie.     Journ.  of  exp.  Med.,  vii.,  1905 
Oppenhtimer.    Carl.     Die   Fermente   u.   ihre  bwlogische  Bedeutung. 

Mod.  Arzt.  Bibliothek,  vol.  16 
Pfeffcr  and  Hofmeister.     Chemische  Organisation  der  Zelle.  Braun- 
schweig, Kyoi 
Pfeiffer.     Wien.  klin.  Woch.,  42,  1906 
Prcti.     Biochem.  Zeit.,  iv.  6 
Reicher.     Wien.  klin.  Woch.,  48,  1907 

Robson  and  Cammidge.     Surgery  of  the  Pancreas,  \m7  _^ 

Schade.     Miinch.  med.  Woch.,  3«,  i907-     "  Diabetes  und  Katalyse 
Schittenhelm  and  Schmid.     Zeit.  f.  exp.  Path.  u.  Ther.,  iv.  2 
Schittenhelm.     Zeit.  f.  physiol.  Chem.,  xliii.  228,  251,  343 
Schumm.     Hofmeister' s  Beitr.,  iv.  c>-n,  v.  vii. 
Schumm.     Zeit.  f.  physiol.  Chem.,  xxxvi.  296 
Sieber  and  Schumfi-Simonowski.     Zeit.  f.  physiol.   Chem.,  xxxvi. 

244  ;   xlix.  50 
Sieber.     Zeit.  f.  physiol.  Chem.,  xxxix.  6 

SUbergleet  and  Mosse.     Beit.  z.  klin.  Med.  Festschrift  Senators,  1904 
Solms.     Zeit.  f.  klin.  Med.,  i,  2,  1904 
Sprig!|S.     Zeit.  f.  physiol.  Ckem.,  xxxv.  480 
Volhard.     Munch,  med.  Woch.,  49,  1903  ;   9.  1907 
Walther.     Die  Arbeit  der  Verdauungsdriisen,  Wiesbaden,  1903 
Wiens.     Deut.  Arch.  f.  klin.  Med.,  xci.  5,  6 
F   Winkler.     Fol.  haematologica,  iv.  3 

Wohlgemuth.     Biochem.     Zeit.,     iv.    271  :      79     Versamml.     deut. 
Naturf.  u.  Aerzte  in  Dresden,  1907  " 


SECTION    II 

AUaria.     Jahrb.  f.  Kinderh.  Ixiii.  i 

Ascoli.     Clin.    med.    Hal.,    12,    1904;     Vorlesmigen    uber    Uramte, 

Jena,  1903 
Asher.     Biochem.  Zeit.,  iii.  335 
Atkins.     Brit.   Med.  Journ.  Feb.  1908 
Benedict.     Biochem.  Zeit.,  iii.  ;   FfiUger's  Archiv,  nS 
Bergell  and  Richter.     Zeit.  f.  exp.  Path.  u.  Ther.,  1905 


jM 


LITKRATURE 


;,  i'K'4 
La  Conductibiliti 


lonen- 


\iu  ktl      "Zur  \.vhTc  von  .Icr  Uitfah.gkcit  des  Scrums  in  L ramie. 

Deutsche  m,d.  Woch.,  2H,  i'^>2  :    also  Ze,t.  f.  khn.  Mai.,  xuoz 
Bilz.     hit  lifsliniw.  (I.  M'^lecurareeiiichts,  i-xu 
Bousma.      Mt'l.   Ivtlsflirifl  i.wi  (iemeskutuls,  li.  . 
Ccconi.     Archif.  per  U  Scume  mediche,  uioi. 

elettrica  del  SiiTo  umano  " 
Colin.     MitUil.  a.  d.  (.nnznih.  d.  Med.  u.  Chir.,  xvn    2 
Fok,  C.     .-irch.  di  l-'iswl.,  i.,  ii. 
HamburKtr.     Hiochen,.  /.eit..  i..  n..  ui.  ;  Fol.  hacm.  n. 

Iflirc  " 
HcrzoK      Xeit.  f.  phvsik.  Cluii:.,  y.  43 

Hob^r      PIns.k.  Chen,,  d.  /elk  u.  dew.,  K/.6  ;   PftiigerS  .-IrfA.r.  iHoo 
V     Koranyi.     Die  wissenschaflltchen  Grundtageu    d.    Kryoskvfte    i» 

ihrer'klin.  Amcemluug.     Mod.  Aerzt.  Bihliothek.  Belt  i 
Moore  and  Koaf.     Diochem.  Journal,  ii.     "  Direct  Measurements  of 

the  Osmotic  Pressure  of  Solutions  of  certain  Colloids 
I'faundler       Verh.   d.   21.   Versammlung.   der    Gesellsch.    /.    Ktnder- 

heilkunde.     Wiesbaden,     1005:    76.     Versamml.    deut.     Saturf. 

u.  Aenle,  Breslau,  1004 
Kichter.     Deri.  klin.  Woch.,  u^)? 
Robert -Tcssot.      Viscosimeter,  Fol.  hacm..  iv.  4 
Rossi.     Arch,  di  Fisiol.,  i.  4 
Sasaki.      Virchow's  Archiv,  clxxxiii.  2 

Schonborn.     Gefrierpunke  u.  Leitfdhig.  Beslimm.  VVi-sbadcn.  IQ04 
Strauss.     Bedeulung  d.   Kryoskopie  f.  d.  Diagnose  u.   Therapie  von 

Sierenerkrankungen.     Mod.  Aerzt.  Bibliothek,  Hefte  4.  5 
Senator.     Deutsche  med.  Woch.,  3.  looo 

Tezncr.     Zeit.  f.  physiol.  Chem.,  liv.  i  ,       .    .^        .    n,     ..    ;„ 

Wilson.     Biochem.   Journal,   ii.     '•  The   Conductivity   of    Blood    in 
Coagulation  " 


SECTION    III 

Albrecht.     Deut.  Zeit.  f.  Chirurg.,  Ixxxvi.  2-4 

Bab,  Hans.     Zeit.  f.  Get.  u.  Gyn.,  p.  60.  u.oj  ;   Munch,  med.  Woch., 

46,  igo7 
H   V   Bennecke.     Miinch.  med.  Woch.,  44.  if^)/ 
Bernert.     Arch.  f.  exp.  Path.  u.  Pharm.,  4Q  ,       ,     •    .      ^, 

Bockelman.     Sederlandsk  Tydschrift  von  Geneeskunde,  1.  6,  1904 
Bodou.     PfliiS^r's  Archiv,  civ.  g-12 
V.  Bokay.     Deut.  med.  Woch.,  47,  igo7 
Bonoli.     Centralhl.  f.  Gyn.,  633.  kkj^ 
Cavazzani.     Centralhl.  f.  Phvsiol.,  x.  145 
Christen.     Zentralbl.  /.  inn.  Med.,  ic;u3-7 
Dencks.     Miinch.  nicd.  Woch.,  37,  1407 
Donath.     Journ.  of  Physiol.,  xxxiii.,  1905 


UTEKATUKE 


269 


Zur  Chcmie  dcr  Zerebro- 


EnRclmann.     Mumh.  med.  Woch.,  41.  «'>'3 
I-ahr.     MitHch.  mcd.  Woch.,  ;,  Hyo8 
Foi.  C.     Arch,  ill  Phy-uologta,  i.  2,  ii;)04 
Fonlos.     CoHiptes  remlus,  51,  56 
Frcnkel-Hciden.    B'ochtm.  Zcit.,  ii.,  i  ^^■ 

si)inalflus8iRkcit  " 
Freunil.     Munch,  med.  Woch.,  7,  igo8 
Fuchs  ami  Rosenthal.     Wien.  med.  Presse,  44-47.  "XM 
Ful.l  and   Lcvison.     Biochem.  Zcit,  si.  A".     "  Die  Feiwinbestim- 

munR  mittcls  dcr  Edestinprobc  " 
Gilbert  and  Castaigne.     Compter  rendus,  ii.  70.  i</x>-4 
Grober.     Munch,  med.  Woch..  8,  1900 
Gross.     Arch.  /.  exp.  Path.,  44 
Gruber  and  Grunbautn.     Miinch.  mcd.    Woch.,  o.  1004  :  Centralbl. 

f.   Phys.,    XV.    315.    I'yos  ;     Verhdl.  d.   physik.   mcd.    Gesellsch. 

Wurshurg,  ,?7.  l<'<^'4 
Griinbaum.  D.     Inaug.  Dissert.  VVurzburg.  kaM 
Gruner.     Biochem.  Journ.,  ii. 

Griinhagen.     PflUger's  Archiv.  43  ,   „    ,   , 

Halliburton.     .-1   Text-book  of  Chemical  Physiology  and  Pathology, 

1891  ;   "Oliver  Sharpey  Lectures,"  Lancet,  May  4.  1907 
Hammarsten.     Zeit.  f.  physiol.  Chem.,  vi.  194 
Hammerfahr.     Munch,  med.  Woch.,  ^A,  1907 
Hasebroek.     Zeit.  /.  physiol.  Chem.,  12 
Herzfeld.     Zeit.  f.  klin.  Med.,  Ixiv.  i,  2 
Heyrovsky.     Wien.  klin.  Woch.,  6,  u,»o8 
Hildebrand.     Deut.  Zeit.  f.  Chirurg.,  Ixxxvi.  5.  6 
Hoffman.     Arch.  f.  exp.  Path.  u.  Pharm.,  xvi.  133 
Hoppe-Seyler.     Lehrbuch  der  physiol.  Chem. 
Hueter.     Ziegler's  Beitrage,  xli.  3 

Jacque.     Bull,  de  I'Acad.  royale  des  Sciences  de  Belgique,  4,  1902 
Joachim.     Munch,  med.  Woch.,  44.  1903 
Jolles.      Wien.  med.  Woch.,  1894 
V.  Ketley  and  v.  Torday.     Deutsche  Arch.  /.  klin   Med.,  Ixxix.  5,  6 

Kofnian'     Ergeb.  d.  Physiol.,  i.  i,  285 

Kossel  and  Freitng.     Zeit.  f.  physiol.  Chem.,  xvii.  45^ 

Kostlivy.     Deut.  Zeit.  f.  Chirurgie,  xci.  3,  4 

Landolf.     Biochem.  Zeit.  vi.  61.    "Differential  analysen  von  Mens- 
chenblut  u.s.w." 

Landwehr.     Zeit.  f.  physiol.  Chem.,  viii.  114,  363 

Langstein.     Jahrb.  Kinderh.,  Iviii.  925 

Lannois  and  Boulard.     Lyons  Medical,  21,  1904 

Lascialfara.     II  Policlinico,  July  1907 

Lehndorf  and  Baumgarten.    -Zeit.  f.  Path.  u.  Ther.,  iv.  2 

Liilenstem.     Miinch.  med.  Woch.,  34,  1907 


IJO 


MTERATL'RE 


Lohnmcycr.     num.. I    m    H,ilhhurlon's   Text-hook  of  Chemical  Phy- 
siology, i«'(i 
Lnthcrsin.     H'len.  kttn.  Rundschau,  I'/i; 
I-iiikc.     Arch    f.  hint.  Chnutg.,  ,? 

Marchand.     Mtil.  (iiselluh.  :u  Leif<:tg,  Juno   ii,   I'xV 
Mam-  and  Ixva.liti.     A>i>u,les  dt  llHshtut  I'usteur,  Fibruar>'  IO07 
MarischU-r  ancJ  Ozarkievvicr.    Archiv.  /.  Verdaiiungshraukhetten,  Qd  v 
Marshall      Jouru.  of  exp.  Med.,  vi.  ,?4".  ><'<>5 
Michi'h  anti  Mattirolo.      Witn    kitv.  Woch.,  Kjckj 
Mieschcr.     Znt.  /.  Phvsiol  Chem..  4 

Mourson  ami  Schla«<lcnhauffcn.     Comptes  rendus,  xiv.  701 
Moynihan.     Midictil  Chronicle,  i<;<)J 
Muilcr.     Deulsches  Arch.  f.  kliit.  Med.,  xci.  ,^84 
Nassauer.     Munch,  med.  W'och.,  7,  I'^xi 
NeuburKcr  and  Strauss.     Zeit.  f.  phxswl.  Chem.,  y-> 
Ncumcistcr.     Physiol.  Chem.,  \>.  47^ 
Niosi.      Virchow's  A'chiv,  Kw 
Nonne  and  Ajiclt.     Arst.  Vereni  in  HavMurg.  Oct.  10.  1Q07  ;   Arch 

f.  Psych,  u.  Scrrenheillt..  Ji.  4.^  "'<^7 
V.  Noorden.     Handhuch  d.  Path.  d.  Stoffwech..  Bd.  i 
Olmcr  and  Audibcrt,     Revue  de  .MfdeciMC,  uxH 
Otori.     Zeit.  f.  phystol.  Chem.,  xliii.  }ii 

Pickardt.     lierl.  klin.  W'och.,  1807 
Pilcz.     Wien.  klin.  Rundschau,  nio' 

Pincussohn.     Diochew.  Zeit..  iv.  4S4 
gung  dcs  Pankrcassattes  " 

Poljakoff.     Berl.  klin.  H'och.,  i.  looo 
Quincke.     Deut.  Arch.  f.  klin.  Med.,  xxx.  5.  ifi 

Raehlmann.     Miinch.  med.  Woch.,  p.  Jo8(),  1003 

Ricken.     Arch.  f.  klin.  Med.,  22,  i8q6 

Rosenbach.     Berl.  klin.  W'och.,  ifKU 

Robson  and  Cammidue.     Surgery  of  the  Pancreas,  1007 

Rumix^.     Berliner  med.   Gesellsch..    July   17.    1^7  ;    Munch,    med 
W'och  .  p.   1507.   iry07 

Runeberg.     Deut.  Arch.  f.  klin.  Med.,  xxiv. 

V.    Rzcntkowski      Berl.  klin.    W'och.,    227,    ir>04 
arzysteva  Lekarskiego  W'arszawskiego,  iii.,  ,V 

Rzentkowski.     Przsglad  Ickarski,  IQ04 

Salm.     Sederl.  Tydsch.  voor  Geneeskunde,  i.  16 

Sasaki.      Virchow's  Archiv,  ii.  183 

Schmidt.     Mitnch.  med.  W'och.,  50.  IW7 

C.  Schmidt.     Hoppe-Seyler's  Lehrbuch 

Schumm.     Zeit.  f.  phvsiol.  Chem..  xxxvi.  jc/i 

Scipiddfs  and  Farcas.     //rf..r'o  BcitySge  :ur.  Geh   u-  Gyn.,  ix.  1 

Sicard.     Soc.  med.  des  hop.  de  Paris,  iqoi 


'  Die  Gefricrpunktserniedri- 


Pamigtuik    Tow- 
i(/)4 


LITERATURE 


«7i 


SlcmcrllnR.     fieri   */i«    Woch..  it,  1004 

Stnzyiowski.      H'l^H    med.  H'ock  ,  4^,  i«J04 

Straus*  and  GroMman      Deutsch*  mtd.  Woch.,ftfy^,  I'lOi  ;    lyf^.  uniy 

StrauM.  H.     Du  chnmtscken  Siertntntxundungtn,  p.  4"-  Berlin,  :■  »t 

Toyasumi.     Miinch.  mtd.  Woch.,  40,  i«jo7 

Vicarclli  and  Cepponp.     Giornale  dtlla  R.  Accademia  di  Mtdtcina 
di  Torino,  I'a>i 

WeyRandt.     Physihalisch  trud.  Gesellsch.  x.  Wiirthurg,  IQ07  :  A/iiwfA. 
med.  Woch..  p.  155,  ifA>7 

Zangcmeister.     Mtinch.  med.  Woch.,  41,  1004 

Zcchuisen.     Ceritralhl.  f.  inn.  Med.,  xl.  «<*6,  1018 

Zock.     Wien.  Mm.  Woih..  15.  uio^ 


SECTION    IV 

Bcmhcim.     Virchow's  Archiv,  131 

Bugarsky  and  TanRl.     Pftiiger's  Archiv,  72,  1898 

Christen.     Zentralbl.  f.  inn.  Med.,  13,  1005 

Citron.     Deutsche  Archiv  f.  klin.  Med.,  4^.    "  Zur  klin.  VViirdigung 

des  Eiweissgchalts  und  des  sp.  G.  patholog.  Fliissigkeiten  " 
D'Este  Emer>'.     Bact.  Diagnosis  for  ^     »iiioners.  1906. 
Engl.     Berl.  klin.  Woch.,  43.  Kjo.l 
Englander.      Munch,    med.    Woch..    i.    1007;     Prager  Zeitsch.    f. 

Heilk.  xxvii.,  ir^/) 
Forssner.     MUnch.  med.  Woch..  i       IQ05 
Gruner.     Biochem.  Journ.,  ii. 

Halliburton.     Text-book  of  Chemical  Physiology,    iSgi 
Hoffmann.     Virchow's  Archiv,  7».     "  Albumen  Content  of    .\scitic 
Fluids";     Virchow's     Archiv,     44.      "Albumen    Content     ot 
CEdema  Fluids  " 
Janobki.     Berl.  klin.  Woch.,  44.  i'^7 

V.  Ketley  and  v.  Torday.     Deul.  Arch.  f.  klin.  Med..  Ixxix..  5,  6 
Landolfi.     Mediz.  klinik.  Ospedale  Incurabili    Xtapoli  ;     Riv.  crit. 

di  Clin,  med.,  4 
Lazarus  Barlow.     Journal  of  Physiol.,  1896 
Mammi.  ^  La  Clin.  med.  Ital.,  3,  1905 

M^hu.     Etudes  sur  les  liquides.     Archiv.  gin.  de  mid.,  v.  7,  1872] 
Miram.     Maly's  Jahrb.,  iQoo 
MuUer.     Deut.  Archiv  /.  klin.  Med.,  xci.  3,  4 
Neuburger  and  «■  rauss.     Zeil.  f.  physiol.  Chem.,  xxxvi.  232 
Neuenkirchen.     Vber  die  Verwandbarkeit  des  sp.  gr.  u.  des  Eiweiss- 

gehaltes.     Diss.  Dor  pat,  1888 
Noel  Paton.     Brit.  Med.  Journ.,  ii.,  1890 
V.  Noorden.     Handbuck  der  Path.  d.  Stoffivechiels,  1907 


27^ 


LITERATURE 


■;-,t 

I  1  5 

I M 

III 


Otori.     Ziit.  f.  Hiilkuii(/i\  xxv.  5.  1004 

Patella.     Ma/y  Jber.,  i,S.S8 

Ranke.      Vher  Piinktionsjiiissi^keiten.     Diss.,  H'iirsbiirg,  1886 

Reiss.     Arch.   f.   exf>.    Path.    it.   Phann.,  51  ;    76.    Versamml.  deut. 

Xatiirf.  H.  Aerzie,  Breslan,  igo4 
Reuss.     lieitrii^.  f.  klin.  Benrtheiluni^\-.  Exiuhitenund  Transudaten. 

Deut.  Arch.  j.  kliu.  Med.,  24,  28 
Rivalta.     //  Policlinico,  xi.,  xii.,  1005 
Roth.     Arch.  f.  Atiat.  11.  Phys.,  iSgg 
Rzentkowski.     Paiiiie'uik     Torwarzystwa     Lekarskiego      Warszaws- 

kie^o,  Bd.  C.  Heft  iii,  igo4 
Rzentkowski.     Bert.  klin.  Woch.,  0,  kx)4 
Runeberg.     Berl.     klin.    Woch.,    3^,    1807,    "Klin.    Studien    iiber 

Transudationsprozesse  im  Organismus,"  Deut.  Archiv.  f.  klin. 

Med.,  34,  3;- 
Scnator.     Virchow's  Archiv,  111.   "  t'ber  Transudation  u.  iiber  den 

Einfluss  dcs  Blutdrucks  auf  die  Beschaffenheit  der  Transudate." 
Stiihelin.     Mihich.    mcd.     Woch.,     laoz.     34.      "  Uber    den    durch 

Essigsaure  fallbaren  Eiweisskorper  der  Exsudate  " 
Strauss.     Deutsche  med.  Woch.,  2,  IQ05.     "  Refractometrv'  " 
Strauss  and  Chajes.     Zeit.  f.  kliu.   Med.,  W-     "  Refractometrische 

Eiwcissbestimmungen  am  menschlichen  Blutserum  " 
StrubcU.     Miinch.  med.  Woch.,  p.  6i(,  1902 
Tedeschi.     Mediz.  Klinik.,  Genua. 
Umber.      Miinch.     med.     Woch.,    10,     1Q05,    "  Zum    Stadium    der 

Eiwcisskorper  in  Exsuclaten  "    Zeit.  f.  klin.  Med.,  xlviii.,  1903 
Wideroe.     Xorsk  Magasin  f.  L'dgevidershahen,   1907 


SECTION    V 


! 


Barjori    nd  Mazucl.     Arch.  Gen.  d.  Med.,  40,  IQ03 

Biberfjeill.     Beitr.   f.  klin.  Med.    Festschrift   Senators,   p.  99,   1904. 

"  Ergebnisse  Zytologischer  I'nter.iuchungen  " 
Brior.     Ceutralhl.  f.  allgcni.  Path.,  xiv.  (j^x) 
Bunting.     John  Hopkins  Hosf>.  Bulletin,  xiv.  185,  1903 
H.  C.  Earl.     Dublin  Journ.  Med.  Science,  1903 
Emanuel.     Lancet,  January  12,  1906 
Etlinger.      Berl.  klin.  Woch.,  46,  itjo" 
(".Dggia.     Gaz:.    degli  Ospedali    ed    Cliniche,     13,    k>05.     "Certain 

Leucocvtc  Forms  in  Cerebrospinal  Fluid  " 
(iramegna.      Rif.  Medica.  28.  IQ04 
Cirawitr.      Uber  geformie  Bestandteile  in  48  pleiiritischen   Exsudaten. 

Charite-Annalen,  xviii.  1893 
Grcnet    and  X'itry.     Comptes   rendus  de  la  Soc.  de  biol.,  25,    1903. 

'■  Cytologic  dcs  -Vscitcs 


LITERATURE 


273 


"  Studien  fiber  Entzundung 


Heinz.     Miinch.  med.  Woch.,  7,  1900. 

seroser  Haute  " 
Jacobsohn.     Medizinskoje  Obosrenife,  12,  1903  ;  Miinch.  med.  Woch., 

p.  1438,  1903.    "  Ubcr  die  Z>-todiagnostik  der  Exsudate  " 
Jagri       IVien.   klin.    Woch.,  40,    1905.     •■  Zur   Farbung  von  Exsa- 

datzellen  " 
Jansen.     Kordisk     Tidschrift   f.     Terapi,    9.     1906;    Munch,  med. 

yyoch.,   p.    1483,    1906.      "  IJber  Zytodiagnostik  von   Pleura- 

ergiissen  " 
JuUiard.     Revue  de  Chirurgie,  1902.     Th6se  de  Geneve,  iwi 
V.  Ketley  and  Arpad  v.  Torday.     Deut.  Arch.  f.  klin.  Med.,  190, 
Ixvii.  I,  2 

Koniger.     Die  zytolog.  Untersuchungsmethoden,     Jena,  1908 
Koster.     Kordiskt  Medicinskt  .-Irkiv,  ii.  38.  4.  1905.     "  Die  Zytologie 

der  Pleura  und  Peritonealergusse  " 
Lewkowicz.     Przeglad  Lekarski,  32-4,  1904;   Wien.  klin.  Woch.,  X2, 

Lotti.  kiv.  critica  di  Clin,  med.,  18.  19.  1904.  "  Contribute  alia 
cytodiagnosi  dei  vcrsamenti  della  sierose  " 

Niedner.     Gesellsch.  d.  Charite  Aerzte,  January  12,  1904 

Patella.  Deutsche  med.  Woch.  ic^2.  "  tJber  die  Zytodiagnose  der 
Ex-  und  Transudate  " 

Quincke.     Deut.  Archiv.  f.  klin.  Med.,  1875 

Raillon.  Thise  de  Paris,  1904.  "Lymphocytosis  of  Cerebro- 
spinal Fluid  " 

Raubitschek.     Zeit.  f.  d.  Grenzgeb.  d.  Med.  u.  Chirurg.,  ix.  2,  6^ 
1906.  ^' 

Roscnbach.     (See  Literatnre  to  Section  III.) 

Sahli.     Lehrbuch  der  klin.  Untersuchungsmethoden,  1905 

Samele.     La  Clin.  med.  Hal.,  2,   1905.     "  Uber   die   Zytologie    der 

Pieuraergiisse  " 
Saw>-er,  J.     Lancet,  February  i,  1908 
Sicard.     Soc.  med.  des  hop.  de  Paris,  1901 

Signorelli.     //  Policlimco  {Sez.  med.  fasc,   10),  1903  ;  "  La  Pleurite 
Lmfomatosa."     La  lUforma  medica,  6,  7,   ic)04.     -  Contribute 
alio  studio  citologico  dei  vcrsamenti  liquidi  infiumonatosi  dclle 
diverse  cirrose  " 
V.  Starck.     Med.  Gesellsch.  in  Kiel,  July  6,  1907 
Stassewicz.     Sitzung  der  Gesellsch.  Russischer  Aerzte  zu  S.  Peters- 
burg, October  22,  1903 
Steinbach.     Inaug.  Dissert.,  Bukarest,  1903 
Symes.      ^edical  Press,  October  4,  1905.     "  Cvtodiagnosis  " 
Vargas-Suarez.     Beitr.  z.  Klinik.  d.  Tuherculose,  ii.  3,  1904      "  Uber 
Lrsprung  und  Bedeutung  der  in  Pleuraergiissen  vorkommenden 
Zellen  ' 


18 


274 


LITERATURE 


Widal  and  Ravaut.     Compt.  rend,  de  la  Soc.  de  bid  de  Paris,  June  30. 
October  13.  December  22,  iqoo  :   La  Prcsse  Mid.,  1901.  etc..  etc. 
Wolff.     Zeit.  f.  klin.  Med.,  xlii.  1901 

CEREBROSPIN.XL     FLUID 

Devaux.     Cer^tralhl.  f.  Nervenhcilk.  u.  Psych.,  J^n^J?.  1903 
Donath.     Lecture   XXXII.,   Meeting   of  Hungarian   Medical   Men 

in  Kolozsvar,  1003 
Fuchs  and  Rosenthal.     Wien.  mcd.  Presse,  xhv.  7,  1904 
Funkc.     Arch.  f.  Dermatol,  u.  Syph.,  Ixix.  340,  1904 
Krctschmer.     Deutsche  med.  IVoch.,  46,  1907 
Luticr.     These  de  Paris,  1Q03 
Merzbacher.     Xeurol.  Zentralbl.,  12,  1904 
Mever      Berl.  klin.  Woch.,  5,  1904 
Nicdncr  and  Mamlock.     Zeit.  f.  klin.  Med.,  liv.  i,  2 
Nonnc      Aerzt.   Verein  in  Ho-'hurg,  October   i,   1Q07 
i'appcnhcim.     Zett.  f.  Heilkunde,  xxviii.  10,  UiOj 
Pcrcheron.     Thdse  de  Paris,  1903 
Preisisch  and  Flesch.     Berl.  klin.  Woch.,  1904.  44-5 
Raubitschek.     Zeit.  f.  d.  Grerrzgeh.  d.  Med.  u.  Chir.,  ix.  2,  6-9.  1906 
Ravaut  and  Darre.     Gazette  des  kopitaux,  August  i  5,  1903 
Sabrazes  and  Muratet.     Soc.  de  Biologic.,  October  31.  November  2., 

1903 
Schlesinger.     Berl.  klin.  Woch.,  28,  1904 
Schwarz  and  Bronstein.     Berl.  klin.  Woch.,  35.  '903 
Siemerling.     Berl.  klin.  Woch.,  21,  1904 
Verzeanu.     Inaitg.  Dissert.  Bukarest,  1903 
Voulcoff.-Montpellier.     Thesis  MM.  Univ.,  No.  6.  1903  4 


Hi 


INDEX   OF    AUTHORS 


i                       Abderhalden,  68,  84 

Burian,  31,  76 

Albrecht,  192 

Burnet,  227 

Allaria,   116 

-                       Apelt,  169 

Cammidgc,  71,  18).  186 

Arrhenius,  7.  94,  loi,  108 

Cappone,  165 

■>                       Ascoli,  70,  85 

Castaigne,  170 

Ashcr,  15,  16 

Cavazzani.  171 

Atkins,   120 

Christen,  159,  199 

[ 

Chvostek,  84 

l;                     Bab,  155 

Claude.  48 

Babesch.  167 

Clemens.  55 

Bacr,  81 

Cohn.  116 

\                        Baldi.  45 

Couerbe,  44 

Bang,  43 
Baumgarten,  170 

Dalmady,  76 

Bayer,  42 

Danilewsky,  44 

;                         Bayliss,  15 

De  Coppet,  92 

Bechhold,  161 

Dencks,  192 

Beckmann,  92 

Deniges,   186 

Beitzke,  88 

D'Este  Emery,   19/ 

Benimelen,  15 

Devaux,  230,  231 

Benedict,  135 

Devillard,   163 

:                        Bennecke,  167 

Devoto,  20 

Bergell,  45 

Dc  Vries,  117 

Bernheim,  197,  199 

Deycke.  14 

Bibergeil,  227 

Diakonow.  45 

Blagden,  92 

Dolgow,  55 

Blum,  72 

Donath.  169,  230,  231 

Bockelman,  162 

Drechsfl,  45,  51 

Bodou,  152 

Drjew^ki,  82 

Bokay,  166 

Durig,  29 

Bonfanti,  70 

Bonoli,  165 

Earl,  228 

Bosanquet,  22 

Ehrlich,  55.  57.  223 

Boulard,  170 

Eichholz,  42 

Brand  berg,  72 

EUingcr,  150 

Bredig,  127,  175 

Engelmann,  190 

Bronstein,  230 

Engl,  203,  204 

Bugai'sky,  tjy.  106,  118 

Englinder,  200 

Bunting,  223,  227 

Eppenstein.  81,  89 

2 

75 

276 


INDEX    OF   AUTHORS 


1 1 


Erbcn.  27,  79,  227 
Eriandscn,  45,  50 

Fahr,  193 

Parkas,  130,  165 

Pels.  125.  126 

Pishcr.  3O,  68 

Pisher,  E.,  10,  65 

Plorence.  194 

Poi,  85,  128,  130,  133,  164,  i'>5 

Forssncr,  209 

Pourcry,  44 

Franchini.  42 

Prankel,  130,  146,  184 

PrenkelHeidon,   167 

Frcny,  44 

Prcunil,  24.  84,  149,  192 

Prey  tag,  146 

Prietlcmann,  i6i 

Priedenthal,  120,  134 

Prk'drichsen,  150 

Pricnd,  i(i2 

Puchs,  172,  173 

Puld,  7Z.  87.  161 

Punke,  231 

Piirbringer,  168 

Piirth,  77 

Geisslcr,  55 
Gilbert,   170 
Gliissner,  185,  202 
Glikin,  42 
Gobley    44 
Gorup    iesanez,  162 
Grawitz,  223 
Grenet,  229 
Grober,  170,  171 
Gross,  159 
Grossman,  159 
Griibc,   165 
Griinbaum,  if)5 
Griinhagen,  164 
Gryns,  215 
Gublor,   142 
Gumprecht,  167 

Halliburton,  42.  143,  14'^'.  '49.  I5'>. 

l6z.    lO''.    1'"),    170      172.    180.    202 

Hamburger,  7,  78,  9'-.  111,  117,  130, 
104,  165.  214,  215 


Hammarsten,  35,  101,  142,  143.  150, 

152.   162,  163.  164,   178-180 
Hamnierfahr,   158 
Hasebrock,   i<>2 
Hausman,  28 
Hcdin,  87.  215 
Hein,  188 
Henriqucs,  51 
Henschcn,  194 
Herz,  140 
Herzleld,   147,  152 
Hess,  7i,  135,  140 
Hesse,  186 
Heyrovsky,  189 
Hildebrand,  191 
Hirschsohn,   187 
Hober,  16,  68,  125,  134.  US.  215 
Hofman,  170 
Hofmeister.  86,  176 
Holborn.   105 
Holland.  58 
i    Hoist,  163 
Hoppc-Seyler,    45,    145,    14O,    148. 

156,  15S,  162,  163,  187 
Hosch,  189 
Huetcr,  184,  188 
Husches,  150 

Ibrahim,  14 
Itallie,  76 
Izar,  85 

Jacobsen,  51 

Jacobsohn,  223 

Jacoby,  72,  84.  86,  88 

Jac<iue,  164 

Jagri,  221 

Jaksch,   151 

J?  .owsky,  205 

Jastrovvitz,  87 

Joachim,  24,  42,  54,  149,  159 

Jochmann,  81,  89,  234 

Jolles,  20,  54,  76,  77,  149 

Julhard,  229 

Ketley,  152.  206,  223 
Keys,  42 
Klemperer.  72 
Kohlrausch,  103,  104,  105 
Koli^ch,  52 


INDEX   OF   AUTHORS 


277 


Koniger.  218,  224,  227,  233 
Koranyi.   104 
Kossel,  146 
Koster,  223 
Kostlivy,    188 
Krause,  178 
Kretschmer,  230 
Kriiger,  31 
Kutscher,  47 

Lagrange,  102 
Landolf,  56,  151 
Landolfi,  208 
Landwehr,  41 
Langstein.  iy,  82,  170 
Lannois,   170 
Lazarus-Barlow,  214 
Leber.  79 
Lehndorff,  170 
Lenhartz,   167 
Lcvaditi,  171 
Levene, 
Levison,  i'<i 
Liebermi.ari,  18,  87,  180 
Licbman,  71 
Liebreich,  44 
Lillenstein,  184,  187 
Limbeck,  120 
Lockemann,  87 
Lohnmeyer,   164 
Lothersin,  159 
Lovatt-Evans,  66 
Ludwig,  182 

Magnus-Levy,  8,;,  85 
Mammi,  208 
r.Ianassc,  48,  50,  51 
Mann,  15,  36,  150 
Marchand,  184,  227 
Marischler,  152 
Marshall,  155 
Mattirolo,  159 
Max,   188 
Mayer,  48 
Mayer,  P.,  51 
Me  Tierz,  51 
Melon,  79 
Merk,  177 
Merkcl,  184 
Meru,  171 


Merzbacher,  230,  231 

Mett,  71,  79 

Michaelis,  12,  44 

Micheli,  159 

Miescher,  146 

Migliarini,  79 

Mitjukoff,  41,  178 

Moore,  B.,  88,  146 

Moore,  F.  C,  48 

Moram,  203 

Morgenroth,  42,  87 

Mosse,  78 

Moiirson,  195 

Mott.  170,  171 

Midler,   81.   85,   89,    155,    163,    171, 

178,  207,  234 
Midler,  F.,  172 
Munk,  143 

Xagel,  176 
Nassauer,  182 
Nawratzki,  167 
Neisser,   161 
Ncubaiier,  58,  82 
Xeuberg,  34,  88,  187 
Xeuburger,  150,  206 
Neumann,  49 
Neumeister,   170 
Niosi,  l88,  189 
Nissl,  167.  169 
Noel  Paton,  203 
Nonne,  169 
Noorden,  55,  144,  203 
Nussbaum,  178 

Obach,  115 
Obermiiller,   187 
Ohrmeycr,  24 
Opie.  81 
Oppenheim,  77 
Ostwald,  69 
Otolski,  42,  48,  51 
Otori,  38,  171,  178,  199 
Overton,  42,  215 
Ozarkiewicz,   152 

Paijkull,  41 

Pappenheira,  58,  77.  232 
Parkes  Weber,  150 
Pascucci,  48 


27^ 


INDEX   OK   AUTHORS 


\n 


31,   14.1.    I45.    '5" 


Patella,  203.  224 
Pauli,  8,  12,  176 
IMaundlcT,  135 
Pft'ffer,  SC.  <)4 
PfciffiT,  Hi 
PfunniK,  1H8 
Pick,   24 
Pickanlt.   13 
Pilcz.  i(>(i 
Pinkussohn.  187 
Poljakotf.   ihi 
Poll,  82 
Prima  vara,  37 

Quevcnnc,  142 

Quincke,  i^ii,  167,  168,  223,  228 

Raaschon,  43 
Raehlmann,   160 
Raoult.  02,  94 

Raubitschek,  223,  228,  230,  231 
Ravaut,  218,  223,  227 
Reale,  23 
Reuss.  197 
Rieken,  167.   168 
Rivalta,  37,  205 
Robson.  71,  184.  186 
Rona,  12.  44 
Rosenstein,   143 
Rosenthal.  172,  173 
Ross,  140 
Roth,  214 
Roiiillcr.  58 
Rumpel.  193 
Runeberg,  200.  201,  204 
Rzentkowski,    147,    151,    152,    203, 
206 


Schittenhelm,  31,  73 
Schlagdenhautten.  19^ 
Schlesinger.  230 
Schlosing,  29 
Schmidt,  148,  172.  184 
Schulz.   15 

Schunim,  79.   185.   186,   187 
Schumoff-Simonowski,  70 
Schwantke,  39 
Schwarz,  230 
Scipiades,   165 
Seliwanotif,  20,  32 
Sicard,  167 
Sieber.  70 

Siemerling,    167,    1O9 
Signorelli.  223 
Silbcrgleet.  78 
Solms.  72 
Sorensen,  74 
Spriggs,   72 
Stahelin,  37.  199.  2"5 
Starck.  148,  227.  228 
Starling,  216 
Stassewicz,  223 
Stecker,  45 
Steinbach,  223 
Stern.  46,  50.  52,  81 
Stozyzowski,  165 
Strauss.  34,  150,  159.  2oC) 
Strauss.  H..  150 

Tangl,  68,  99,  106 
Tedeschi,  208,  209 
Tezner,  107 
Thicrfelder,  46,  50.  52 
Thudichum.  44.  45,  46 
Torday,  76.  152,  206.  223 


Sahli.  166.  170.  218 
Saleesky.   125.   126 
Saliev,  55 
Salkowski,   29,   39- 

163.  180.  194 
Salm.  164 
Sasaki,  116.  155 
Sawyer.  231 
Schade,  88 
Schere,   165 
Scherer.  28 
Schitf,  187 


Umber,  10,  26.  27,  30,  36,  37,  190, 
207 

49,   60.   62,   83.       Vages.  150 

van't  Hort.  69,  92.  94 

i    V,  Bemmelen,  15 

I 

I    V.  Bennecke,   167  i 

V.  Bokay,  166 

V,  Dalmady,  76 

v.  Fiirth,  yj 

V.  Hoist.  163 

V.  ItallJc,  76 


INDEX   OF  AUTHORS 


279 


V.  KctK'y,  152.  206,  223 
V.  Noorden,  55.  203,  144 
V.  Starck.  148,  227.  228 
V.  Torday.  76.  152,  2(y),  223 
Vargas-Suarez,   223 
Vauquelin.  44 
Verzeneau,  230,  231 
Vicarelli.   165 
Vitry,  229 
Volhard.  71.  73,  62 

Wachsmuth,  162 
Walth  r,  71 
Weidel,  31 
Weiss,  55 
Weygandt.  171 
Weyl,  165 

Widal,  218.  223,  227 
Wideroc.  206 


Wiener,  82 
Willanen,  20 
Wohlgemuth,  71.  88 
Wolff.  223 
Wright,  119,  126,  219 

Yorn,  172 

Zaky,  48 

Zanetti.  41 

Zangemeister,    144,    147,    165,    i8j, 

184,  i88 
Ziingerle,  38 
Zeehuisen,  187 
Zeynek,  182 
Zieglwallner,  192 
Zilwa,  185 
Zock,  157  ; 


INDEX 


[The  thickened  figures  indicate  main  references] 


A 

Abdominal  cysts.   187 

Absence    of    hetcrolytic    power    as 

antiferment,  81 
Absolute    acidity    of    aqueous    hu- 
mour,   i'>4 
Absorption  of  effusions,  83 
Acetic  anhydride,   186,   187 
Acetone  in  exudates,  20(1 

pancreatic  cysts,   185 

Achloride  electrolytes.  60.  loi.  162, 

lf.5,    172 
Action  of  antitoxin,  89  (footnote) 
Action  of  blue  li^ht  on  catalysis,  65 
Action    of    lecithin    on    pancreatic 

juice,   88 
Action     of     sotlium     chloride     on 

catalysis,   87 
Action     of     sodium     chloride     on 

peroxydase,  87 
Action     of     sodium     chloride     on 

trypsin,   87 
Action     of     sulphates     on     tryptic 

digestion,  87 
Actual  ions,   122 
Adamkiewitz  reaction,   37,  59 
Adsorption,  12,  14-16,  60,  105,  130 
Alanin,   5 
Albumen,   11,  23,   202  ;    estimation 

of,     14  ;      inhibitory     effect     on 

conductivity.   99 
.\lbumose-N,   82 
Albumoscs.  25.  26,  36,  83,  84 
Aldehyde  test  for  tyrosin,  35 
Aleuronat,  81 
Allantoic  cysts,    189 
Allantoic  fluid.  164 
Allautoin,  151,  165 
Alloxan,  31 


a-Ruanylic  acid,  43 
a-naphthol,  36,  56,  77,  190 
a-naphthylisocyanate.   34 
a-thymonuclcate  of  soila,  75 
Amid-N,  29.  199 
Amidolipoids,  45 
Amidomyelin.  45,  53 
.\mino-acids.  87.   149 
Ammonia,  5.  84.  85,  150,  199,  207  ; 
in  pseudo-niucin,  38 
'   Amniotic  fluid,   133,  U14. 
Amount  of  total  proteid,   199 
An.esthesia.  relation  of  lecithin  to, 

42 

Analysis  of  puncture-fluids,  scheme 

19 
Angiosarcoma  of  liver.    190 
Antifernients,    24.    66,    70,    81,    82, 

86,   88,    89,    149,    155.    163.    164, 

165,  171.  207 
Antipyrin  in  exudates.  208 
Apomyelin.   53 
Apparatus     for     determining    C„, 

129;    electroconductivity,   112 
Aqueous  humour.   133.    164 
I   Argining.  5.  33,  38,  84 
'  Arrhenius  formula,   103 
Asparagic  acid,  38.  84 
Aspartic  acid,  5,  28 
Asi;ociation    of    anti-emulsin    with 

globulin,  88  ;  lecithin  ditto,  209 
Autolysis,  (54,  81,  82,  83.  84,  85,  I  ^ 
Autolytic  ferments,  70,  81 


B 

Bence- Jones  proteid,  5,  ^y,  150 
Benzoic  anhydride,  187 
Benzoylising  pseudomucin,  38,  39 
^-naphthalenesulphaminoacids,  27 


281 


2H3 


INDKX 


Bil.-aciils.  170 

HiU-pigni.  nt,  lii.  !""■  «87.  i8.» 
HiinoK'ciilar  p  iction,  '>; 
Biologii;al  ilivMiictions  botwitn  pro 

,  viik'tii     of  antikTimnts,  87 

r.iiirit  I'  iction.  37 

Bli)0<l-i  '■pii'^cU'  nu'thoii,  i''4 

Burwii:  s  tfsl,  31 


Cidmium  salts  of  licithin,  40 
Calculation  of  amount  of  albumin 

from  sp,  liT.,  i<)7.  no 
concentration  of  H  ions,  131 

—  —  iloKn-i'  of  dissociation,  ij') 

—  —  I'iiuivalcnt  conductivity.  11') 
niols  and  ions,  103 

tonipcrature  coctticit-nt,  106 

capacity,  1 14 

Capillary  olectromcti-r,  175 

Carbaminic  acid,  170 

Carcinoma  cells,  characters  of.  226, 
228 

Casein  method  for  estimating  tryp- 
sin.  73 

Catalases,  70,  77 

Catalase  in  amniotic  fluid,  165 

Catalysis,  (15 

Cells    of    carcinomatous    effusion, 

3.4 
ovarian  cysts,  181.  232 

Cephalin,  45,  53 

Cerebellum,  cysts  of,  ii)4 

Cercbrinazids,  45 

Cerebrosides,  45 

Cerebrospinal  fluid,  23.  133,  if>6, 
167,  169.  210.  229 

Cerebrum,  cysts  of,  193 

Chemical  examination  of  puncture- 
fluids.  10 

Chemistry  of  cells,  234 

ChloricKs.  estimation  of,  (ii 

—  in  amniotic  fluid,  165 

nephritic  effusions,  3 

ovarian  cy=t"i,  iSi  3 

Chloride  i'.  achloride  electrolytes, 
209 


Chlorine  retention   in   transudates, 

«54 

Cholesterin.  42.  51,  52.  143-  M''- 
l^H.  lf)2.  I'M.  182.  185.  186,  187. 
188,  189,  191 

Cholin.  34.  3'^'.  42.  4'>.  >7".  '7" 

Chondroitinsulphuric  aciil.  40 

Christens  formula,  199 

Chyle,  i,'59 

Chylopericardium,  162 

Chylous  ascites,   158 

Cobra-venom  and  jecorin,  51 

Collection  of  fluids,  197 

Colloidal  metals,  action  on  auto- 
lysis. (15.  Wi.  85 

—  characters  of  puncture-fluids.  1 1 

—  contents  of  ovarian  cysts.  174 
Composition   of  ovarian   cyst   con- 
tents. 180 

Concentration-chain  nietho<l.  128 
Concentration  of  electrolytes.    102, 

104 
hydrogen  ions.  145.   155.  J^'4. 

1O5.  172 

non-electrolytes,  104 

Conductivity,  uses  of  determining, 

97 
Critical  solution  point,  120.  121 

Cruorin,  45 

Cryoscopic  determination.  104 
Cryoscopy  method.  7.  15.  93.  • '" 
Crystallographic  characters  of  glu- 
cosamine. 39 
Cystic  lymphangioma.  188,  192 
Cystin.  5.  84 
Cysts  of  bone.  193 

Wolffian  body.  180 

Cytodiagnosis  9.  218.  section,  V. 

D 

Degenerate  cells,  224,  225.  231,  232 
Degree  of  dissociation,  98,  99,  loo, 

108.  190 
3-niethyl  furfurol,  186 
Diiiiges'  test.  35.  186 
Dermoid  cysts.  188.  189.  194 
Determination     of     clectroconduc- 

tivity.  III 
molecular  weight,  92 


INDEX 


283 


/t 


Pfiitfroallximosc,  20,  fiQ,  S4 
D«ycki'   and    Ihrahitn's   iiu-thoil   of 

cstimatinK  albiimt-n.  14 
Diaci'toiu- alcohol,  127 
Diamiilopho^phatKls.  45 
Diaminoacid-*.  13.  ^^ 
Diaminoaciil  mtroRen,  J') 
Piastasi-.  70,   I'J.  !>*'> 
Diazoacitic  itlur  imthotl.  ny 
Diazobeiizcm-sulphonic  acul.  31.  35 
Diazo  reaction.  55 
Diilectricity  constant.  I"S 
DiHtTc-ntial  countiiiK  of  ci'lls,  221 

—  iliaKnosisot  rxiulatcs  from  trans- 

udates, I<j6  sjq. 

—  tensimeter,  120 

—  tust     between     tubercular     and 
other  pus.  8q 

Dittkulties  in  interpreting  results,  6 

removing  albumen,  11 

Dilatometer  method,  127 
DissfKiation,  <>3,  <»5'  ''**■  '■^3 
Drjewezki's  method,  82,  83 
Dulcite,  78.  80 
Dysglobulin,  24 


Edestin,  72,  161 

Ettect  of  amount  of  albumen  on 
specific  gravity,  197 

repeated  tapping,  i  j'l 

temperature  on  conductivity, 

105 
-  —  osmotic  pressure.  92 

viscosity  on  velocity  of  enzy- 
matic reactions.  140 

Eggwhite.  electrical  charges,  175 

Ehrlich's  glucosamine  test,  3f>.  57. 
190 

Electrical   charge   of   colloids.    160, 

161,  175 
Electro-conductivity,  7.  I5'  ^S'  '"■ 

i').5.  175 
Electrodes,  treatment  of,  X13 

Electrolytes.  97.  145.  •47.  ^7^'  ^7<i- 

183 
Endocellular  fluid,  133 

Endoenzyme.-..  35 

Endothelial  cells,  225 


Knterokinase.  88 

Enzymatic     reactions,     heat     pro- 
duction, ')8 
Eosinophile  cells.  227 

granules,  nature  of.  234 

Eppensteins    method    of    detection 

of  antiferinents,  89 
Eiiuivalent  conduitivity.  115 
Hrlaiidsen's  nutho  I.  .V> 
Erepsin.  70 
Errors  in  methods  of  stuily.  ,"5.  5". 

118.  204.  224.  22y  229 
Estimation  of  albumen.  14,  201 

autolysis.  81 

working  jwwer  of  kidney.  7 

Ethyl  butyrate.  71.  79.  «" 
I'.uglobulin.  24.  37 
Kuseriimalbumen.  23 
Explanation   of   reaction   of   Iwxly- 
1        Huids.  134 

I ditterence    in    chemical    com- 

I       position  of  l)ody  fluids.  21') 


False  pancreatic  cysts.  184 
Fatty  acid  crystals,  ii^ 
Ferments,  4.  $'■  64.  8'.    '55-    '^'4- 
165.  171.  185.  20f) 

—  action  of.  (>4 

—  classification  of.  70 

—  experiments  with.  78-80 

—  heat-production  by.  08 

—  in  fluids.  80 

—  in  leucocytes.  79 

—  methods  of   detecting   and   esti 
mating.  70 

—  relation    to   inorganic 

—  specificity  of,  68 
Fibroblasts.  224 
Filtration-nitrogen.  144 
Fish-albumen.  0 
Florence  reaction,  194 
Foa's  results.  133 

Formalin,    action    o.n    ferments    of 

leucocytes.    8 1 
Formic  acid.  38 

Formula  for  c.ilculating  C».  132 
mols  +  ions.  103-4 


ferments. 


284 


IMtKX 


FiiriiiiilH  {»T  corrrctinif  (or  albunu-n, 

KM) 

._   .-.  —  —  tcmjHTiitiiri'.  107 

—       intir|Mil.itinK.  loj 

FriTziiiK  point  iltpn-i^iDn,  <(5.    i'><>. 

1')^,  i«s 
Friction  iKtwoi'n  mils,  nm,  locj 
Friictosf,  150,  io*.,  ^(jH 
Furoxyluim  ti'st,   jj 

('. 

Galactose  in  crrcliro-spinal  fliiul.  170 
Gas  ilectro<li-.   I  iH  ((oolnoti) 
Gasfs,  'K),  143,  i^z 
Gflatin  for  (ictfctinu  lirniriits.  Hi 
Gloliiilin.  24.  J5,  8«,   m.   147.   14>). 

151).  iM,  i(<i.  Ki.j.   U<4.  I'.v  1''^- 

201 
Glucosanun.  5.  .^5,  .^i.  .1'* 
Glucose  in  tiiiiils,   145,   170 
Gliitaininic  aculs,  5,  3H.  84 
Glyciropliosplioric  acid.  4M,  41J 
GlyccKoll.  5.  28.  3.;,  38.  84 
Glycogen     under     ultramicroscope, 

Glvcoyen-reaction      in      carcinoma 

cells,   J  28 
Glyco-proteids.  35,  1 78 
Glycuronic  acid,  37 
Glyoxylic  acid,  38,  58 
Gol>let-cells,  174 
Graphic  methods,   102 
—  representation  of  acidity,  124 
Guanase,  75 
Guanidin,  38 
Gynesin,  47 

H 

Haematoidin  crystals,  233 
Haematonu-tra,  184 
Haemin  crystals.  186 
Haemolysis,  42,  51.  155 
Haemorrhagic  cysts  of  cerebellum, 

194 
Hamburger's   blood-corpuscle 

method,  8,  lU>,  117 
Hausmann's  method,  28 
Heinz'  researches,  221 


Hesse-S.ilkowikrh  test,   186 

Hrleroalbiiii>o-.<',  5,  '1.  2" 

Meterolytit  ferment  actio.i,  81 

Hi-.tidin,  5,  35.  55.  84 

Mt^lone.  38 

Huniiii  Mibst.-inces.  38 

ny<l.itid  lyst.  i}.  57,  i'),  14".  189, 

210 
Hydraeima,  2<k> 
Hvilroctle  fluid,  IO3.  2ti) 
Hydrogen  electro<le.   128 
Hydrolytic  ferments.  70 
Hydronephrosis.  |(>l 
Hydrothorax.  14<> 
Hydroxyl  ions  in  bloo<l.  135 

I 

Iml>il)itio:i.   i-'i 
Immune  seruin  reaction,  208 
Importance  ot  early  exaimn.ition  of 
Hiiids,  1 1 

—  NaCl  to  liody.  87  (footnote) 
Inilicators.  122.  I2^ 

Inhibition   of   conductivity    l>y   al- 
buiiun,  <>•> 
-  dissociation,  i)<k  107 
Inhibitory  effect  of  friction.  100 
Inorganic  colloiils  on  aiitol>  sis,  85 

—  constituents   of   puncture-fluids. 
(«> 

Inosite  in  hydrocele  fluid,  if>4 
Intercellular    substances,     permea- 
bility of.  2  if) 
Interpolation   by   graphic    method, 
;        102 
Invertase.  71 
Inversion  method.  126 
Iodides  in  exudates,  2o3 
Ionic  concentration,  <>7 
Ionic  theory.  7,  94,  122 
Iridium  electrodes,  130 
Isobutylhydantoic  aciil,  28 


Jagri's  nu'tho<l,  221 
lecorin.  45.  51 
Jenners  stain.  219 
Joint  fluids,  cells  in,  229 


INDEX 


»«! 


K 

Keratin.  5 

K)tl<ta»ilisinR,  2<».  3«.  Ji.  75.  "'•  ^'• 

I') I,  ii>4 
KohUr 's  apparatii>t.  11 1  (footnoti) 

I 

Lacteal  cysts.  i<n 
Lactic  acid.  H5.  170 
I^ctoHo,  78.  Ho 
I^KruiiXc'^t  lormula.  loi 
Laniloll's  nifthoil  of  .inalysis,  151       1 
LarKi'  nioiiomiclfar  colls,  il^,  iji 
Laws  of  osmotic  pri-ssurc,  <>i 
Lecithin.  3^.  4a.  47.  4'»-  5.«.  ^5'  *"'■ 
14''.  '47.  '5".  '.VJ.  "'•'■  "'3'  ^'"'^ 
classification.    45  ;     history.    44  ; 
imiwrtance  of.  42,  44  ;    methotl   ; 
of  analysis.  48  ;   optical  varieties. 
47  ;    properties  ot.  4')  ;    relation 
to    cell-ferments.     44.     4''*  :      '" 
cholesterin.  42.  48  ;  to  neunn.  47  ; 
to  nucleic  acitls.  43  ;    to  X-rays. 
44  ;   tests  for,  4') 
Leucaemia.  79.  81 
Leucin,  5.  27.  38.  84.  146,  150,  187, 

207 
Levulinic  aciil,  38 
Levulosc.  21,  31.  3a 
Liebermann's  reaction.  37.  i8^ 
Lijiase.  70.  71.  79.  i'>5.  18'),  208 
Lipoids.  42 
Lner  cysts,  189 

Liver,  pathology  of  metal)olism.  3 
Lufflcr's  serum,  81.  89 
Lumbar  puncture,  i(y(f 
Lymph,  142 
Lymphatic  cysts,  192 
Lymphocytes.  82,  222 
Lysatinin,  33 
Lysin.  5.  6,  33,  34,  38,  84 

M 

Magnesium  sulphate,   for  diagnosis 

of  cerebrospinal  ffuul,  1O9 
Manasse's  method,  50 
Mannitc.  78,  So 
Mast  cells,  228 


.Mastic  tor  removini?  albumen.  12 

.Mastites.   147 

MeaninK  '»f  terms  atul  and  base.  7 

acidity.  123 
Meat  extract,  new  bas  s  in.  47 
Mesenteric  cysts.  1H8 
Metabolic    ,irotlucts    of    carcinoma 

colls,  214 
Motalbiimon  in  hydr.Kole  flui<l.  I'H 
Methaenioxlobin.   i  S7 
Method  of  oxidising  organic  matter 

rapiilly,   50 
Methtxis    of    analysis    (ue    under 

special  headings) 
Methoils  of  preparing  films,  219 
Methyl  acetate  method.  127 
Methylguaniilin.  47 
.Methylphonylgliicosazono,  it 
Methylpyriilin  chloride,  47 
Michaelis    and    Konas    metho<l    of 

removing  albumen,  13 
MicriKhomical  reactions,  50 
Microscopic   characters  of   ovarian 

cysts.  177 
Milky  effusions.  15H.  192 
Millons  reagent.  35.  j7,  38.  206 
Mimicking  antifornient  action,  87 
Mingm,  47 

Mixtures  of  electrolytes  and   non- 
electrolytes,   107 
Mcxle  of  existence  of  ferments  within 
the  cell.  8(> 
'    Mode  of    interaction  between  elec- 
trolyses and  nonelct   ■.   .,  tos.  107 
Molecular    concentration     of    exu- 
ilates  and  transudates.  2o'> 
I   — conductivity.  115 
!    —  depression,  93 
Molecules  plu:i  ions,  </>,  103 
Molisch  reaction,  y>,  37,  5') 
Mollusc  albumen.  6 
Monamidophosphatids.  45 
Monamid  X.  29.  182 
Monaminoacids.  13,  20.  27 
Monomolecular  reaction,  <)7 
Morner's  test  tor  tyrosin,  35 
Mucin,  20,  36.  40,  41,  151.  160,  l'>3, 

165,  178 
Mucoid  contents  of   ovarian  cysts, 
174 


% 


2S6 


INDEX 


Nakayania's  list,  5') 

Niosin.  47 

Nt'iiinann's  method,  4') 

N'curin.  ?4 

Neutral  iioiiit,   1  J4 

NitroKi-n  contt-nt  of  lyniiih,  144 

Non-i'kttrolytts.   104 

Normal  HCl,  3') 

NovaiiH',  47 

Nuck'ar  changes  in  Koblot  cells,  1 78 

Nuclease,  70,  75 

Nucleo  glol)Lilin,  24.  141* 

Nticleoliistone,  40 

Nucleoproteid,  20.  170 

O 

Object    ,f  study  ol  punctiire-tluids. 


Objeci 


to   Hausinan's   nutluxl. 


Oblitin,  47 

Oedema-Fluid,  ('l 

Omental  cysts,  189 

Oitalescent  fluids,  151.  1.58 

Oral  administration  of  diugs,  208 

Orcm  test,  32 

Osmosis,  <)i 

Osmotic     concentration,     t/'.      108, 

144,  147.  '5-.  >54.  15".  "'.V   '"-■ 
182,   187,   188 

—  pressure,  92,  104 

—  work,  <»3 

Ovarian  cysi,  25,  41.  54.  ."i'l.  '".  80, 

85,  141,  173,  180,  232.  251 
Ovomucin,  24 
Oxalic  acid,  38 
Oxidation,  influence  of  arsenic  on, 

Oxyaminoacids,  34 
Oxydase,  70,  76,  77 
Oxygen  electrode,  129 

1' 

Pancreatic  cysts,    23,    59,   80,    184, 

185 
—  juice,  composition  of,  133,  185 
p-bromphenylhydrazine  test,  a 
Para,s;lobulin,  24,  I49 
Paralactic  acid,  i')4 


Paralbumen,  yt.  41,  if>3 
Paramucin   41,  178 
Paranephric  cyst.   191 
Paranucleins.  40 
Parapseud<)j;lobulin,  24 
Parasitic  cvsts,   194 
Parotid  cysts,  193 
Parovarian  cyst.  181 
Pathological  metabolism  in  liver,  3 
I'atholosy    of    metabolism,     study 

Pentainethylenediamine,  84 

Pentoses.  32.  37,  84 

lVl)siii,  71,  I'l.i,  180 

Peptones.  25,  84 

Pericardial  fluid,  61,  133,  l^)i,  i''2 

IVripancreatic  cysts,  189 

Peritoneal    fluid,     critical     solution 

point.  121,  133,  148 
Pernuabihly     of     carcinoma   cells, 

-=•7 
cells  in  peritone;d  fluid,  4 

1 to  ions,  214 

, cnilothelial  cells.  215 

■ inflamed    serous    membranes, 

21 1 
1    Peroxydase,  77,  87 
i    Phenolphthalein,   126 
Phenylalanin.  5 
I'hloroglucin,  33 
Phosphatids,  42,  .52 
Phosphorus,  detection  of.  49 
I    Phosphotungstic  acid.  13 
Pliysical    jiroperties  of    proteids  in 

turbul  effusions,  160 
Physico-chemical    characters    of 
fluids,  152.   182   (see  Electrolytes, 
etc.) 
examination  of   puncture-fluids, 

91  sqq. 

Phvsico-chemistry,  to  supplement 
chemical  study  of  puncture-fluid. 
2 

Pickardt's  method  of  removing  al- 
bumen, 13 

Picrolonic  acid,  171 

Pigments.  59.  127 

Pinas  test  for  ty  rosin,  35 

Platinum  electrodes.  130 

Pleural  fluids,  34,  85.  ^S.  '48.  227 


INDEX 


287 


Poisonous  action  of  txudatcs  and 

transudatfs.  15^) 
I'olarimttry,  bq.  126,  151 
Polymerisation  in  fluids,  107 
Polynucleosis.  223,  224 
Polypeptids.  13 
I'otassium     salts     in     fluids,     14^'- 

172 
Potential  ions,  122 
Practical  value  of  autolysis,  82 
Precipitins.  78 

Preformation  of   proteid   constitu- 
ents, 44 
Preliminary  separation  of  chemical 

const:*  jents,  20,  21 
Pressure    of    contents    of    ovarian 

cysts.  1 7'^' 
Procedure  for  determining  C,,.  131 
Prolin,  5 

Propionic  anhydride,  187 
Protagon,  44 
I'rotallnimose,  5,  6,  20 
I'rotamin,  5 

Proteid  Extractive  Ratio,  i'^2.  203 
Protcid  of  carcinoma  cells,  3 
Proteid    quotient,    143,     ia9.    i<^'2' 

201 
Proteolytic  ferment.  81.  234 
Pseudochylous  effusions,  ifti 
Pseudoglobulin,    24,     37,    A^.     54- 

149 
Pscudolymphocytes,  222,  224,  225 
Pscudomucin,  35,  38.  178 
Pseudomyxoma  peritonei,  184 
Pseudoserumalbumen,  24 
Puerperal  changes  in  uterus,  83 
Purin  N.,  83,  199 
Purins,  20,  29,  31,  76 
Pus,  loi,  145 
I'jTocatcchin,  170 
Pyrrhol,  58,  77 


Q. 

Quinone  test  for  tyrosin.  35 


Rate  of  flow  of  cerebrospinal  fluid, 
232 


Ratio  of  chlorides  to  achloridcs,  8, 

100.  loi 
Reducing-powcr  of  puncture-fluids, 

7<i 
Reductonovain.  47 
Retractive-coefficients      of      fluids, 

204 
Refractomctry.  140,  203 
Relation    of    ferments    to   lecithin. 
86 

'-ccifi:  pninl        to       specific 

gra    ity,    109 
Rena    ;ysts.  190 
Resi(.id    litrogen,  33    ;,4.  150.  168. 

199 
Results  afforded  by  cytodiagnosis, 

221 
Retroperitoneal  cvsts,  189 
Reversible  reactions.  68 
Ricin.  72 

Rivalta's  test,  37,  205 
Rosolic  acid   test   for  paralbumen, 

Runcberg's    method    of    estimating 
albumen,  201 


Salol-splitting  ferment,  165 
Salting  out  proteids,  22 
Salt  ratios.  143.  U'i.  236 
Sarcolactic  acid,  164 
Sarcoma  cells.  224 
Saturated  ammonium  sulphate,  37 
Scheme  for  differential  diagnosis  of 
cells,  233 

—  of  chemical  analysis,  8 

Scherer's  test,  28 

Schitf's  test,  187 

Schlosing's  method,  29 

Secretion  of  goblet  cells,  39.  4° 

Separation  of  globulins,  22 

glycoproteids,  36 

Serin,  5 

Serosamucin,  36,  40,  205 

Serum  albumen,  5 

Serum,  concentration  of  hydrogen 
ions,  133 

Sorbose,  32 

Sorenscn's  method,  74,  75 


288 


INDKX 


Sources  of  error  in  p"rforming 
cryoscopy,  i  lo 

failure  in  practical  diagnosis. 

218 

Specific  conductivity.  100  (foot- 
note), 115 

Specific  gravity.  io<j,  i<)7 

Spermatocele.  1<J4 

Sphingomyelin.  45,  53 

Spleen  cysts,  ii)Z 

Sputum-niMcin,  3<j,  40 

Stereo-isomeric  variations  of  pro- 
teids.  6 

Stern  and  Thierfelder's  methoil,  5c, 

Structure  of  proteids,  5 

Study  of  pathology  of  metabolism. 

3 
Subcutaneous     ledema     fluid,     34, 

53 
Substances     inipenneable     to     red 

cells,  8 
Successive  tapping,  I'x) 
Succinic  acid,  21.  84,  85,  114.  194 
Sugars  in  peritoneal  fiuitl,  150 
Sulphuretted  hydrogen,  84 
Surface  tension,  13.  174 
Symbiosis.  209 
Synovial  fluid,  163 
Synovin.  163 


Temperature-coefficient,   106 
Temperature,     correction  -  formula 

for,  107 
—  effect  on  C-,,.  130 

conductivity,  105 

• viscosity.  139 

Tezner's  experiments,  108 

Thermostat,  114 

Thymin,  84 

Thymolphthalein,  74 

Thyroid  cysts,  187 

Total  nitrogen,  82,  199.  207 

Transudate  v.  Mxudate,  0,  Section 

IV. 
Trimethylaniine,  47 
Tropxolin  OOO,  126 
Trypsin,  73,  81,  186 


!   Tryptophane,  5,  57,  58,  59,  84,  162, 
190 
Tubercular  pus,  89.  146 
Tubo-ovarian  cysts,  182 
Tumour  cells  in  cerebrospinal  fluiil. 

Turbid     effusions.     54,      I58.     l52 

167 
Types  of  effusion.  23 
Tyrosin.  5.  34,  35,  38.  55,  84,  107, 

150 


U 

Undercooling,  no 

Urachal  cysts.  189 

Uracil.  84 

Urea,  29,  143.  163,  164.  165.  192 

Uric  acid  in  Huids,  148,  165 

Urine,  133.  191 

Urobilin,  151 

Urochrome,  55 

Use  of  conductivity  method,  97 

determination     of     viscosity, 

140 

Giemsa,  221 

refractometry.  204 

sand  time-glass.  221 

slides  for  tilnis,  220 


V 

Vacuolated  cells,  229 

Valerianic  acid,  38 

Value  of  determination  of  con- 
ductivity, 116 

failures  in  diagnosis,  7 

study  of  chemistry  of  effu- 
sions,   10 

Van't  Hoff's  law,  95,  107 

Variations  in  chloride  content  of 
fluids.  210 

Velocity  of  reaction.  65.  23,  83 

Vidiatin,  47 

Viscosimeter  of  Hess,  72.  135-8 

Viscosity.  108.  135.  173.  205 

—  method  of  determining,  137 

—  precautions  needed,  137 

—  influence  of  temperature.  139 

—  results,  140,  141 


INDEX                                                 289 

\  itrioiis  humour,  C  ,.  of,  133 

X 

Volatile  aculs,  8";,  146 

Xanthiii  bases,  40,  84 
Xanthin,  estimation  of,  75 

W 

Xanthin  oxydase,  70,  76 

Xyli<lin  test,  33 

Wassirmann's  reaction,  164 

Weil  Ill's  test,  .?l 

Z 

Wideroe's  test,  206 

WriKht's    method    of    determining 

Zymogen    granules    in    leucocytes. 

osmotic  pressure,  119 

234 

"9 


I. UN  HON 
II,     "<       l,l;WI-^,     i;'-I.O\Vili    SiKM.l,     W.l 


